ASSIST Online Membership Application

Note: Only one person may be registered at a time. If you would like to register
two or more members, please complete the registration process for each
registrant separately.

MEMBERSHIP YEAR:

2006 (January 1, 2006 -- December 31, 2006)

Are you a NEW member or RENEWING your membership?

I am a NEW member.
I am RENEWING my membership.

Please select your MEMBERSHIP TYPE:

Regular Voting Member - $150.00 (Annually)
Vendor Member - $250.00 (Annually)
Associate Member - $25.00 (Annually)
Employee Member - $25.00 (Annually)

Note: Please complete all that apply (fields in red are required).


Full Name (Registrant):

Title:

Company:

TPSB License Number:

Address:

City: State: Zip:

County:

Phone:  Fax:

E-mail Address:

Website Address:

Social Security Number*:
*Required for C.E. credit/certificate purposes only.

Please make sure your information is correct and press "Continue" below to proceed to a secure payment area.

Important: It may take a few moments for the payment page to appear, so please be patient (do not press "Continue" more than once). You must complete the payment portion of your registration or your information will not be processed.