Renew Your Affiliate Membership Today! (Non-profits & University types ONLY)

May 1, 2010 - May 31, 2011

If you are a non-profit or university type organization and you have been an Affiliate IPSA member within the last 2 years, please register your renewal by filling out the following form.

Register Online

Please complete the form below. After completion, you will have the option to pay with PayPal.

Company Name

Primary Contact

Address

City

State Select one AL AK AZ AR CA CO CT DE DC FL GA HI ID IL IN IA KS KY LA ME MD MA MI MN MS MO MT NE NV NH NJ NM NY NC ND OH OK OR PA RI SC SD TN TX UT VT VA WA WV WI WY

Phone

Toll Free Number

Fax

Web Site

Email Addresses for Key Contacts

please list the email addresses for each key contact in your organization

Type of Operation

Sole Proprietorship
Partnership
Subsidiary of Outside Corporation
Family/Independently Owned
Closely-held Corporation
Other

Affiliate Dues Classification Select one $250.00

Method of Payment

Pay online
Pay by check
Please send an invoice

please indicate your method of payment

Only fill out this form if you have been an Affiliate member of IPSA within the last 2 years

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