MEMBERSHIP APPLICATION
Note: Membership year is June 1 - May 31.  Dues are renewed annually.

First Name

Last Name

Mailing Street Address

City

State

Zip Code

Business Phone

Fax Phone

Home Phone

Profession

Years in Practice

Graduate Degrees

Type of Membership

Full

Associate

Student

Organizational

Dual

Signature

_______________________________________________________________________

Date

Please mail your application along with your check made payable to:

WISER * P.O. Box 15186 * Chevy Chase, MD 20825-5186

Yearly Membership Dues

Full Member

$95.00

Associate Member

$50.00

Student Member

$25.00

Organizational Member

$175.00

Dual Membership

$225.00