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| Name | * |  | PLEASE SHOW YOUR NAME AS YOU WISH FOR IT TO APPEAR ON YOUR MEMBERSHIP CARD |
| Business Name | | |
| Street or P.O. Box | * | |
| City | * | |
| State | * | |
| Zip Code | * | |
| Business Phone (no dashes) | * | |
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| Home Address or PO Box | | |
| City | | |
| State | | |
| Home Phone (no dashes) | | |
| Name of Spouse | | |
| E-Mail | | |
| Date of Birth |  | |
| Fax | | |
| Years of experience in accounting | | |
| Years of experience in public practice | | |
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| If yes, EA# | | |
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| If yes, CPA# and State | | |
| If yes, Certificate # | | |
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| If yes, certificate # | | |
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| If yes, certificate # | | |
| Degree(s) you hold | | |
| School(s) and Year(s) Attended | | |
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| If yes, Date | | |
| Nat. or State Tax/Acct. Assoc. You Hold Membership | | |
| Reference: Name | | | REFERENCE MAY BE CONTACTED AS TO YOUR CHARACTER, ABILITY, AND DEGREE OF PROFESSIONALISM |
| Street or P.O. Box | | |
| City | | |
| State | | |
| Zip Code | | |
| Reference: Name | | |
| Street or P.O. Box | | |
| City | | |
| State | | |
| Zip | | |
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| MEMBERSHIP SPECIAL (NO INITIATION FEE) | | | MEMBERSHIP THROUGH MARCH 31, 2012 |
For a description of memberships available, select MEMBERSHIP CLASSIFICATIONS under JOIN IAAI on the Menu Bar.Annual membership dues are payable on April 1st of each year. |
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| Initiation Fee | | | ONE TIME FEE |
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| Membership Fees | | |
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| Street or PO Box | | |
| State | | |
| | Total: $
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| | Payment Options |
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