Application for Associate Membership
The information provided below will be listed in the IAL Directory, and will determine where IAL correspondences will be sent. Please print or type.
Company or Organization Name ______________________________________________
Mailing Address ___________________________________________________________
State _____ Zip ______________
Telephone ___ - ___ - ______
An Associate Membership is designed for suppliers, manufacturers, health care organizations and service companies who provide medical support to laryngectomees. These members have no voting rights but may participate as committee members if requested. Dues will be determined by a recommendation from the Bylaws Committee to the Board of Directors. In no case will the dues be less than that of the largest IAL Club.
If you have any questions:
Signed: _____________________________________________ Date ___ /___ /_____
Please sign and mail your minimum payment of $175.00 to the address below:
925B Peachtree St. NE, Suite 316
Atlanta, GA 30309
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