Name:

Address:

City, State:		Zip Code:

Telephone:		Email:

ALPCA Number (current or previous members)

1.	Have you ever been a member of ALPCA?  YES NO If yes, write your previous membership number above so we can reactivate you.
2.	Check either "New Membership" or "Renewal"   New Membership - Retroactive to January 1 of the current calendar year.   Renewal - Effective January 1 of the next calendar year.
3.	Membership Type and Term: New memberships and renewals are now available for periods between 1 and 5 years. To United States/Canada/Mexico:  First Class Mail - $42/year To United States only:  Second Class Mail - $32/year  Junior (under 18) - $19/year       Birthyear:  To All Other Jurisdictions:  Foreign Global Priority - $75/year Term:   years (1 to 5)
4.	Method of Payment (All payments must be in U.S. Funds): Check / Money Order enclosed Bill my credit card (indicate which type): American Express MasterCard  Visa Name exactly as it appears on card:  Card Number:   Expires:  Signature:

Please mail this completed form and appropriate payment to:

ALPCA, Inc. 118 Quaker Rd Hampton VA 23669-2024

In consideration of the benefits of membership in ALPCA, each member agrees to abide by the ALPCA By-laws, its procedures and policies, as well as the principles of ethical practice.