ILA Membership Application

Give the Gift of Listening

An ILA Membership

Please fill out the following form in its entirety. Required fields are indicated in bold.

About the Recipient
Name:
Email Address:
Affiliation:
Street Address:
Street Address:
City:
State:
Zip/Postal Code:
Country:
Phone:
Fax:
Employer:
Title/Position:

Please check up to three of the following INTEREST AREAS for the recipient:

Business	Legal	Research
Consulting	Helping Professions	Special Education
Elementary Education	Secondary Education	College/University
Other (please specify)

In which of the areas above is the recipient's main employment?

Please check the MEMBERSHIP CATEGORY you prefer to give to the recipient:

Regular, $95.00: Membership status, ILA Newsletter (Listening Post), International Journal of Listening, and Annual Directory of ILA Members

Sustaining, $295.00: Includes all privileges of Regular members, plus Conference Registration

Organizational, $535.00: Includes Annual Membership and Conference Registration for TWO people, one copy of Journal, Directory, and Newsletters

Lifetime Membership, $1,000.00 (May be paid in 5 yearly installments of $250.00): Includes Lifetime Membership and all printed materials. Reduced Conference Registration fee.

Student, $45.00: Includes all privileges of Regular membership for a full-time student (Limit of 5 years). Specify school and year

You may print and fax or mail this form, or you may submit your application online. NOTE: Your credit card information will not go through a secure server. You may wish to call 877-8-LISTEN with your card number after submitting this form.

Method of Payment

Credit Card Number Exp Date

Note: A membership kit will be sent to the recipient upon receipt of your payment in full.

About the Gift Giver (You)
Your Name:
Email Address:
Affiliation:
Street Address:
Street Address:
City:
State:
Zip/Postal Code:
Country:
Phone:
Fax:

How did you (the gift giver) hear about the ILA?

Note to attach to membership packet when it is sent to the recipient

Snail Mail Directions: If you choose to snail-mail your Membership Application, please fill out this form online, print it, and snail-mail it to:

International Listening Association
Dr. Nan Johnson-Curiskis
Executive Director, International Listening Association
Box 164
Belle Plaine, MN 56011
info@listen.org (www.listen.org)
952-594-5697; 877-8-LISTEN
(Please leave a message if no answer)

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For more information on the ILA, please e-mail our Executive Director, or call us at 1-800-ILA-4505 or 715-425-3377.

Updated June 17, 2005

Joyce Chen, Web Editor