| CONTACT
INFORMATION |
|
| First
Name: |
|
| Last
Name: |
|
| Middle
Initial: |
|
| Position/Title: |
|
| Institutional/Organizational
Affiliation: |
|
| Daytime
Phone: |
|
| Fax: |
|
| Email: |
|
| PREFERRED
MAILING ADDRESS |
|
| Address,
line 1: |
|
| Address,
line 2: |
|
| City: |
|
| State: |
|
| ZIP: |
|
| Country: |
|
| |
|
| Referred
By: |
|
| |
|
Preferred
Chapter Affiliation (if any):
(refer to NAME website for chapter
list)
|
|
| |
|
| Type
of Institution/Affiliation: |
|
| |
|
| MEMBERSHIP
CATEGORY
|
(Please
check one category, plus the electronic subscription to Multicultural
Perspectives, an official journal of the National Association for
Multicultural Education, if interested)
|
| |
Institutional
Memberships:
(operating budget > $25,000)
Lifetime
Memberships:
|
| |
|
| |
|
| DIVERSITY
DONATION |
(tax-deductible) |
| I
am including an additional amount to support NAME scholarships and advocacy
efforts. |
$
|
| |
|
| Mailing
Lists |
|
| NAME
has my permission to include my name on mailing lists. Mailing lists
are only provided to groups that support NAME's goals. |
Yes
No |
| |
|
| |
|
