Membership Application

Dues: (Circle one)
          Individual Dues with electronic Newsletter    $25.00
          Individual Dues with hard copy Newsletter    $35.00

Make Check payable to IADCCT

Send to:
          Elaine Herbert
          IADCCT Financial Director
          3434 West Earll Drive, Suite 101
          Phoenix, AZ 85017

(Circle one)    RENEWAL        NEW MEMBER

(Print Clearly or Type)
Name _____________________________________________
Address (as it should appear for mailing)
_________________________________________________
_________________________________________________
_________________________________________________
_________________________________________________
Country ________________________________
Home Phone ________________ Work Phone ________________
E Mail Address _________________________________________
Date Certified (approx) _____________________________________
Year, City, State (where Certified) _______________________________
Have you ever been a member before? (Circle one)          Yes         No
If Yes, what year did you first join? ____________________
Please include a photocopy of your certification or have a Duncan Ambassador, Duncan Distributor or Dealer who can verify your eligibility sign below to attest to your eligibility.
_________________________________________________
Ambassador, Distributor, Dealer                                                            Date