Full Name:                      

Home Address:                   

Home City, State Zip:           

Company:                        

Company Address:                

Company City, State Zip:        

Phone Number:                   

Fax Number:                     

E-mail Address:                

I would like the following type of membership:
General Membership - $60.00 per year. Student Membership - $10.00 per year. Associate Membership - $40.00 per year. Institutional Membership - $250.00 per year.

Accepted forms of payment:      or   or   

I would like to pay for my membership using the following method:
Visa Master Card Personal Check

I will submit payment for my membership using the following method:
Telephone Fax U. S. Mail

Please note that you must submit your payment to the MAEP Executive Director via telephone or fax for credit card payments, or U. S. Mail if by personal check to the appropriate number/address below.

Lynne Kohon, MAEP Executive Director
Phone: (517) 349-1970
Fax: (517) 349-9949
Email: Lynne Kohon