Please fill out the form below. This is the first step in the registration process.
The information below is collected for USPA's records. It is also used to match you against
the online membership purchase made in step two, through our credit card processor Click & Pledge.
If you have any questions, please contact webadmin@uspermafrost.org

Personal Information Check marks indicate required fields
Name :
Email Address :	Phone Number :	Fax Number :
Address :
City :	State : Alabama Alaska Arizona Arkansas California Colorado Connecticut Delaware District of Columbia Florida Georgia Hawaii Idaho Illinois Indiana Iowa Kansas Kentucky Louisiana Maine Maryland Massachusetts Michigan Minnesota Mississippi Missouri Montana Nebraska Nevada New Hampshire New Jersey New Mexico New York North Carolina North Dakota Ohio Oklahoma Oregon Pennsylvania Puerto Rico Rhode Island South Carolina South Dakota Tennessee Texas Utah Vermont Virginia Washington West Virginia Wisconsin Wyoming	Zip Code :

Membership Options
Membership Type	Membership Years
Student Membership: $10 / year Individual Membership: $20 / year Corporate Membership: $100 / year Institutional Membership: $100 / year Sustaining Membership: $250 / year Lifetime Membership: $1000	2010     2011     2012
Additional Membership:	Membership Years
None Student Membership: $10 / year Individual Membership: $20 / year Corporate Membership: $100 / year Institutional Membership: $100 / year Sustaining Membership: $250 / year Lifetime Membership: $1000	2010     2011     2012
Optional Scholarship Contribution
	( $10. $20, $30, $40, $50.. )

Professional Information ( If applicable )
Job Title :	Profession :
Employer :	Employer Affiliation : Federal State Other Government University Private Org. Private Citizen Business Self-Employed Volunteer Other

Corporate and Institutional Information ( If applicable )
Representative Contact Name:	Representative Contact Phone :
Representative Contact Email :

Student Information ( If applicable )
Name of College or University:	Degree Program
	BS MS PhD Other
Anticipated Graduation Date:
( MM/DD/YYYY)

Volunteer Opportunities
Would you be interested in serve on a committee?	Would you be willing to serve as a USPA officer?
No Thanks Educational Workshops Awards Committee Fundraising Committee By-Laws Committee Website Committee	No Thanks Vice President, President-Elect Secretary Treasurer Board Member