Individual Membership Registration Form - DOC by 1YJWzRJ6


									                                                                                                                      Individual Membership Application
                                                                                                                      $50 USD Annual Fee
                                                                                                                      For information regarding Bronze, Silver, Gold, or Platinum
                                                                                                                      memberships, write to –

  INSTRUCTIONS: Thank you for your interest in ICPA and in supporting its                                      By Mail:         Attn: Cassandra Johnson
  mission and goals. This membership application form should be completed in                                                    International Corrections and Prisons Association
  English and all areas should be filled in where applicable. Your details will be                                              1619 Sumter Street
  held on our database which is maintained by ICPA administrative staff. This                                                   Columbia, South Carolina 29201, USA
  form may be completed and sent by mail or fax as noted:                                                      By Fax:          +1 803 779 8518
                                        Online membership applications and/or renewals are also available via our website at

CURRENT STATUS                          Today’s Date:
                                                                  MONTH        DAY        YEAR
                                                                                                                        NEW MEMBERSHIP                 RENEWAL

CONTACT DETAILS                        Salutation:                                      (Mr., Mrs., Ms., Dr., etc.)                              ICPA maintains a member database from
                                                                                                                                                  which contact information may be made
 Please complete ALL fields.                                                                                                                      available to members upon inquiry.
 Missing information will delay        First Name:                                                                                                Please check here if you DO NOT wish to
 the completion of your                                                                                                                           have your contact details disclosed.
 registration.                         Last Name:
                                       Gender:                  MALE                    FEMALE
                                       Date of Birth:                                                                  First Language:
                                                                  MONTH       DAY
                                                                                                                       Spoken Languages:


                                       Agency Type:              GOVERNMENT             NON-PROFIT                    ACADEMIC            PRIVATE SECTOR              OTHER
                                       City:                                                                           State/Province:
                                       Country:                                                                        Post Code:
                                       Office Telephone:                                                               Mobile Telephone:
                                       Email:                                                                          Fax:
                                       Company Website:

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 you learned about ICPA.

Credit Cards                                                                                                              Wire Transfers
Credit card payments are processed in $CAD and include a 1% processing fee.                                               PLEASE NOTE THAT ICPA’S WIRE TRANSFER INSTRUCTIONS
Please print clearly and return by fax or mail to the above address.                                                      HAVE CHANGED.
Name on Card                                                               Card Type
                                                                                                                          Please contact Cassandra Johnson for instructions.
Card No.                                                                   Expiration                                     (
                                                                                           MONTH      YEAR

Checks / Money Orders:                  Please make payable to: International Corrections and Prisons Association. Mail to address above.

                                        WELCOME TO ICPA AND THANK YOU FOR YOUR SUPPORT!
                                    Interact with other members of ICPA at our online community website –

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