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<br />IA\~I <br />\I:::Y!9!I <br /> <br />AssoCiation <br /> <br />mNllf1tlCllpilolSUeet,NE <br />-... <br />Wnhingtlm, DC2IlllOZ-4.:101 <br /> <br />leMA Membership Application (for non-local government professionals) <br /> <br />This fonn is for first-time leMA members of the private sector, academia, or federal/state government. Fonner <br />members should call 202-962-3680 for a reinstatement form. (Type information directly onto form, save in your <br />personal drive, and email to membershiDIQ)icma,or~ as an attachment. Or, write information and return the form <br />by mail or fax,) <br /> <br />Date: <br /> <br />Category: <br /> <br />D Professor at college/university (prof) D Other (afnis) <br /> <br /> . <br />Prefix: Full name: I Nickname: <br />Title: Employer: <br />CODtlId lafol'lDlllioD Please send ICMA """li"8l' to: U business address below o home address below <br />Mailing address or PO box: <br />City: State: ZIP: I Country: <br />Business phone: Business fax: Business Email: <br /> <br />A. Personal Information (optional) <br /> <br />I Date of birth (mmlddlyyyy): <br /> <br />I Gender: DMale <br /> <br />DFemale <br /> <br />Race: DAsian DAfrican-American DCaucasian DNative American DOther Hispanic background? Dyes DNo <br /> <br />B. Interest Areas (optional) <br /> <br />I~dicate any areas of interest (e.g., brownfields, urban design, transportation, public safety, environmeot, etc.): <br />1____ j <br /> <br />C. Pavment <br /> <br />ICMA dues are not deductible as a charitable contribution for federal income tax purposes. Please submit payment in U.S. <br />currency. Fees: Not worldngfor local government $180 College/university professor $165 <br /> <br />1""*- ~- <br />Credit card #: <br />Print cardbolder's name: <br /> <br />~EspreIII OV... <br />ExpiIation date: <br /> <br />DMaIlaCard <br />I Amount: <br /> <br />Sign ifpaying by credit cord and mailing or faxingform: <br /> <br />Date <br /> <br />Return fonn to: ICMA Member Servicesl777 North Capitol St NE #500lWashington, DC 20002. Or fax with credit card <br />infonnation to 202-962-3565. ContaCl202-962-3680 if yon have questions. <br /> <br />Office Use Only (afnis/proj): Date ---1---1_ Staff <br /> <br /># <br /> <br />NL:N <br />