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Date ______________________

Membership Information (mark all that apply):

__ New Membership

__ Membership Renewal

__ Information Update

__ Address Change for Mailing List

Please update the following information:

Name:____________________________________ Title: ________________

Organization's Name: _____________________________________________

Preferred Mailing Address: __ Home __ Office

Street:_________________________________________________________

City:_____________________________________ State: _______Zip:_______

Daytime Telephone: (______)____________________ Extension:___________

Alternate Telephone: (______)____________________

FAX Number: (_____)_______________________

E-mail Address:________________________________

Dues Enclosed:

Dues include a subscription to the Chapter's newsletter, Parameter.

Chicago Chapter Membership

__ $15.00 Regular Rate

__ $6.00 Student Rate

__ $0.00 Chapter membership paid through National ASA

Please make check payable to: Chicago Chapter ASA

and mail to:

Chicago Chapter ASA
PO Box 7259
Chicago, IL 60680