BECOME A MEMBER

Please fill out the application below and click the "Submit Application" button to send to our membership chair, Dr. Rick Martinez, or click here to get at PDF version of our membership brochure that you can print out and mail.

*NAME:	REQUIRED
DATE OF APPLICATION:
MAILING ADDRESS:
CITY:
STATE:		ZIP CODE:	COUNTRY:
*EMAIL:	REQUIRED
*PHONE:	REQUIRED		FAX:
HIGHEST DEGREE:
DATE AWARDED:			AWARDING INSTITUTION:
CURRENT PROFESSIONAL ACTIVITIES:	(CHECK ALL THAT APPLY) TEACHING RESEARCH CLINICAL ADMINISTRATION OTHER (PLEASE SPECIFY)
ETHNIC SELF IDENTIFICATION:	AFRICAN AMERICAN/BLACK AMERICAN INDIAN/ALASKA NATIVE EURO-AMERICAN ASIAN/PACIFIC ISLANDER LATINO/HISPANIC OTHER (PLEASE SPECIFY) BI-MULTI-RACIAL (SPECIFY)
WHAT ARE THE TWO MOST IMPORTANT ISSUES YOU WOULD LIKE TO SEE THE ASSOCIATION ADDRESS?		1.
		2.
IN WHAT MEMBER CAPACITY WOULD YOU LIKE TO SERVE CLPA?		COMMITTEE MEMBER (CHECK ALL THAT APPLY) Publications Publications - Spanish Translation Committee Public Policy Membership Finance Program Development Student/Early Career Marketing Other areas of interest ELECTED OFFICE OTHER (PLEASE SPECIFY):

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