Individual Membership Application

Date:

Name of Applicant:

Position Title:

Company / Service:

Phone:

 Fax:

Email:

Office / Division / Bureau:

 Dept. / Agency:

Home Business Address:

City:

State/Zip:

Sponsor:

Are you available for:
Speaking on a subject in your field of expertise:Yes No
Serving as an officer for the Institute:Yes No

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 Annual membership dues are:

Government & Academia	$100.00
Industry	$120.00
Government Retired	$50.00
Industry Retired	$60.00
Student	$25.00

Dues are payable with application. Annual membership status runs from September to September with new members joining after April 30 automatically in membership status for the following NIPHLE year.

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Bill My: Visa Master Card American Express

Account Number: Expiration Date:

Signature: _____________________________________________

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Please make checks payable to NIPHLE and mail with application to:
NIPHLE - 177 Fairsom Court - Lewisburg, PA 17837-6844

niphle@dejazzd.com

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