Member Name:       LI#:
Company Name:  
Address:             
City:                    ST: Zip: -
Phone:                 -  Fax: -
e-mail address:                     
                                                                                                                                                                    
                                                                                                                                                                  
Membership expires August 31st each Year!
Annual D. I. A. Full Membership dues are $125.00 per year and include an 8 hour CEU Class. 
Associate Membership excluding CEU Class ( includes manufacturers and additional members from same company) is $75.00 per year. 
Student Membership (includes student and retired members) is $45.00 each per year.


Name: LI#:   Associate or Individual
Name: LI#:   Associate or Individual
Name: LI#:   Associate or Individual

Method of Payment:                                                   Amount: $
Check: #:           or      Pay at the Door   (For MemberCEU Class Only)     Mastercard or Visa also accepted (circle one)

Credit card number: ___________________________________  Expiration Date __________________________

Name on Credit Card ____________________________________________________________________________

Address of Card ________________________________________________________________________________