IAOM Membership Application

Application for (check one):  
Active Membership          Junior Membership          Associate Membership
   
GENERAL INFORMATION  
   
Last Name:
First Name:
Middle Name:
Fourth Name:
Company Name:
Company Address:
Company City:
Company State:
Company Zip/Postal Code:
Company Country:
Company Phone:
Company Fax:
E-Mail:
Position in Company:
Residence Address:
Residence City:
Residence State:
Residence Zip/Postal Code:
Residence Country:
Home Phone #:
To which address do you prefer your IAOM mail delivered?

Business Address          Home Address

 
 
BUSINESS/SERVICE INDUSTRY EXPERIENCE INFORMATION
   
Company Name:
From:
To:
Position:
   
Company Name:
From:
To:
Position:
   
Company Name:
From:
To:
Position:
   
Company Name:
From:
To:
Position:

 

ADVANCED EDUCATION INFORMATION (education beyond high school)
 
Name of Institution:
Location:
Degree:
Date Graduated:

 

PAYMENT INFORMATION

  
VISA          MASTERCARD          AMERICAN EXPRESS  DISCOVER 
Card #:
Expiration Date:
Name as it appears on card:

I, the undersigned, do hereby make application for membership, and agree to comply with all laws, rules, and regulations of the IAOM. I hereby tender $ in USA funds drawn on a USA bank (Active or Associate - $195 Junior Active - $30), to be returned to me if my application is rejected. I agree to pay annual dues in like amount, or such sum as may be established by the Board of Directors in the future.

Signature Date

Mail application form with Check or Money Order (in U.S. funds, drawn on a U.S. Bank), made payable to: IAOM, or use American Express, Discover, MasterCard, or Visa credit card.

Revenue ACT (H.R. 3545), Section 10701 (a) Remittances to the IAOM are not deductible as charitable contributions for federal USA income tax purposes. However, dues payments are deductible by members as an ordinary and necessary business expense.
 

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10100 West 87th Street, Suite 306, Overland Park, Kansas 66212 USA • Phone: 913 338-3377 • Fax: 913 338-3553 • info@iaom.info