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<br />leMA Membership Application. <br /> <br />(for u.s. local government employoes) <br /> <br />leMA membership is for individuals and is not transferable. If you have been a <br />member within the last five years. contact Member Services at 202.962-3680 or <br />membership@icma,org for a reinstatement form. <br /> <br />__i...,-.org <br />zoz...z.suo. rea 202._.1_ <br /> <br />Please print clearly. <br />o Mr. OMs. <br /> <br />lIffioe Use 0lIl, <br /> <br />Date: <br /> <br />Middll!lnitial <br /> <br />""Na... <br /> <br />""'" <br /> <br />Staff, <br />iMIS#: <br />NL, Y_ N_ <br />Ctgry, <br /> <br />FirJtName <br /> <br />Nidtname <br /> <br />...i..... <br /> <br />'''''''''''' <br /> <br />T'" <br /> <br />Stnet. Adrhss or PO Box for maUlngs <br /> <br />Cfty <br /> <br />..... <br /> <br />ZIP <br /> <br />.....,,, <br /> <br />Bus. E-man <br /> <br />....."""" <br /> <br />~ <br /> <br />Stnet: Adch!SsIPO Boll. <br /> <br />..... <br /> <br />ZIP <br /> <br />Cfty <br /> <br />"""""""" <br /> <br />I-bme [-mil <br /> <br />Send ICMA mailings to: 0 Business street address 0 Business PO Box 0 Home <br />Send leMA email communications to: (J BusinE5S emall 0 Home email <br /> <br />........... Information <br />Personal information is used by leMA to better acquaint itself with the membership. This information will not be used to discriminate <br />against any individual or group. regardless of age, race, national origin, marital status, or gender. <br /> <br />1. Date of birth (nunlddlyyyy) <br /> <br />2. Are you of Hispanic ethnic background? 0 Yes 0 No <br /> <br />3. Gender: 0 Male 0 Female <br /> <br />4. Race: 0 Asian 0 Natlve American 0 African-American 0 Caucasian 0 Other <br /> <br />5. Partner's name (if applicable): <br /> <br />first Name <br /> <br />IJnt Name (If c:lfferent from JOUB) <br /> <br />~, <br /> <br />~ <br /> <br />- <br />