Membership Registration Form MEMBER INFORMATION Name: (Title) (First) (Mid. Init.) (Last) Primary E-mail: Position/Title: Alternate E-mail: Work Address: Home Address: (Agency Name) (Street Address or P.O. Box) (Street Address or P.O. Box) (City) (State) (Zip) (City) (State) (Zip) Home Phone: - - Work Phone: - - Cell Phone: - - Work Fax: - - Please indicate your membership status. Regular Member: NEW Provides supervising and/or consulting services in mathematics as a member of the staff of an education agency of a U.S. state/territory or Canadian Province (or agency Regular Member: Renewal designee, upon approval of the ASSM Executive Board). ($50 membership fee) If you are renewing your membership, please state the date when you became an ASSM regular member (month/year): / Associate Member: NEW Held continuous Regular Membership for two or more and no longer meets criteria for Regular Membership. Associate Member status must be approved by Associate Member: Renewal the ASSM Executive Board. ($50 membership fee) Emeritus Member: New Retired from position while a Regular Member of ASSM. (no membership fee) Date of Emeritus Status (month/year): / Please return completed registration form and payment to the ASSM Vice President for Membership: E-mail: Home address: Teaching and Learning Joleigh Honey Salt Lake City, UT 84114-4200 2079 E Debeers Drive Sandy, UT 84093 ASSM. Please make checks payable to OR work address: Utah State Board of Education c/o Joleigh Honey 250 E 500 So
Membership Registration Form MEMBER INFORMATION Name: (Title) (First) (Mid. Init.) (Last) Position/Title: Work Address: (Agency Name) (Street Address or P.O. Box) (City) (State) (Zip) Work Phone: - - Work Fax: - - Primary E-mail: Alternate E-mail: Home Address: (Street Address or P.O. Box) (City) (State) (Zip) Home Phone: - - Cell Phone: - - Please indicate your membership status. Regular Member: NEW Regular Member: Renewal ($50 membership fee) Provides supervising and/or consulting services in mathematics as a member of the staff of an education agency of a U.S. state/territory or Canadian Province (or agency designee, upon approval of the ASSM Executive Board). If you are renewing your membership, please state the date when you became an ASSM regular member (month/year): / Associate Member: NEW Associate Member: Renewal ($50 membership fee) Held continuous Regular Membership for two or more and no longer meets criteria for Regular Membership. Associate Member status must be approved by the ASSM Executive Board. Emeritus Member: New (no membership fee) Retired from position while a Regular Member of ASSM. Date of Emeritus Status (month/year): / Please return completed registration form and payment to the ASSM Vice President for Membership: E-mail: Home address: Joleigh Honey 2079 E Debeers Drive Sandy, UT 84093 Please make checks payable to ASSM. OR work address: Utah State Board of Education c/o Joleigh Honey 250 E 500 So Teaching and Learning Salt Lake City, UT 84114-4200
ASSM_Membership_Reg_Form.docx