MEMBERSHIP APPLICATION FORM

DATE ________________	Please check one: ____NEW MEMBER ____RENEWAL
(APALA Membership year is from January 1 to December 31)

NAME LAST______________________FIRST______________________MIDDLE_______________

POSITION___________________________________________________________________

ORGANIZATION______________________________________________________________

PREFERRED ADDRESS: _____ Work _____ Home

---

WORK ADDRESS	HOME ADDRESS
___________________________________	___________________________________
___________________________________	___________________________________
CITY_______________________________	CITY_______________________________
STATE _______ ZIP_____________	STATE _______ ZIP_____________
PHONE: (Office)_____________________	PHONE: (Home)_____________________
Fax: (Office)_________________________	Fax: (Home)_________________________
E-MAIL ADDRESS ___________________________________________________________
(Optional) Please describe your HERITAGE _______________________________________

---

Indicate, in order of preference, the committees on which you wish to serve APALA
(See lists of committees in APALA Directory):

1.____________________________________________________________________________

2.____________________________________________________________________________

---

MEMBERSHIP CATEGORY:

__Personal ($20) __Student ($10) __Institutional ($50) __Life Membership ($300)

DUE: $_____

Ching-chih Chen Leadership Award Fund: $_____

APALA General Operation Fund: $_____

TOTAL AMOUNT:$_____ ** Donation to APALA is tax-deductible to the extent allowed by law

---

Please mail the completed form with check (payable to APALA) to:

APALA Membership
c/o Gary Colmenar
P.O. Box 1592
Goleta, CA 93116-1592