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APSE Membership Form: Page 1 of 3
Applicant Information

If you are an existing member needing to renew your membership, please log in in order to renew. If you do not have your username and password, please email Jenny Levet to request your login information.


First Name: 

Last Name: 

Organization: 

Job title: 


Address 1: 

Address 2: 

City: 

State: 

Zip: 

Country: 


Email: 

Phone: 

Fax: 


I am a(n): 
Citizen with a disability
Family member
Student (not yet working in the field)
Employer
Professional
Other    (specify)


My organization is a(n): 
For-profit business
Local agency
State agency
Federal agency
Advocacy organization
SE provider
School
University
Rehab provider
Other    (specify)


How did you hear of APSE? 
Friend
Co-worker
Employer
APSE web site
APSE brochure
Internet search engine
          please specify:
Other web site
          please specify:
APSE chapter conference / training
APSE chapter brochure
Conference exhibit
          please specify:
Business associate
Advocacy organization
School or university
Facebook
Twitter
LinkedIn


 


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