NAISTD Membership Registration

• Name*
  First Last
• Job Title*
• Organization*
• Organization's Address*
  Street Address City AlabamaAlaskaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaOhioOklahomaOregonPennsylvaniaRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific State ZIP Code
• Email*
• Phone*
• Fax
• Website
• Organization's Description
  This information will be used in the Membership Directory Update (one paragraph please)
• Special Needs
  • Special Dietary Requirements (please explain below)
  • Assistive Listening Device
  • Alternate Format Materials
• List Other Specific Needs
• Membership Categories*
  • NAISTD Member
  • Guest (attending only receptions and dinner)
  • Observer (site selectors, consultants)
  • Exhibitor
• Payment Type*
  • Check
  • Purchase Order (P.O.)
  • PayPal ($10 surcharge per member)
• Name of person making Paypal payment on attendees behalf (if applicable).
  First Last
• CAPTCHA

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