IEMA Membership Form

Please enter the following information:

Name(Last, First, MI)________________________________________

Title______________________________________________________

Institution/Agency__________________________________________

Mailing address_____________________________________________

Mailing City, State, Zip______________________________________

Home Phone_________________________Home Fax______________

Home email________________________________________________

Business Phone____________________ Fax______________________

Business email address_______________________________________

Business web page address____________________________________

Please check:

Level of Work:

K-12

Elementary

MS/JH

Secondary

Higher Ed.

AEA

Commercial

Retired

Student

Other

AEA: (1-16)_________

House District #: or Representative's name______________________

Senate District #: or Senator's name___________________________

Type of Membership:

Regurlar (http://www.iema-ia.org/spacer.gif)

Student ($15)

Retired ($15)

Commercial ($35)

What committee would you be willing to work on?______________________

Mail to: IEMA Membership, 2306 Sixth, Harlan, IA 51537

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