MPCA / MACA : Membership Application / Renewal Form

2005 Membership Only Application / Renewal Form

Use this form if you want to apply only for membership but not attend the 2005 conference. If you want to get membership and to attend the conference, please use the Conference and Membership Combined Registration form.

Name

Business Address
Department

College or University

City/State/ZIP

Phone

Fax

E-mail
(We will use this only for conference and membership announcements, no junk.)
Home Address
Street

City/State/ZIP

Phone

Fax

E-mail
(We will use this only for conference and membership announcements, no junk.)
Where do you prefer snail mail to be sent?
Business Address
Home Address

Membership Dues for Calendar Year 2005
Regular: $60
Student/Retired/Unemployed: $40

Circle one
if applicable:

Student

Retired

Unemployed

Membership fee must be postmarked by September 15, 2005, to avoid the $15 late fee if you attend the conference. Late fee is waived for residents of countries other than the USA or Canada.
Payment must be in U.S. dollars and made payable to NIU.
Please return this form with your payment (payable to NIU) to:
Gary Burns
Department of Communication
Northern Illinois University
DeKalb, IL 60115
Thank you!