Associate Member Application

Application for Associate Membership


Preferred Mailing Address:

Office Phone(s):

Home Phone:

Additional Phone(s):


Please explain your interest in IPSA membership:


Educational Background

Institution and Field of Study:

Credentials, training, affiliations related to your interest in IPSA membership:

Number of years you worked as a Surrogate (circle)   0             1-5             5-10              11-19             20+

Mail application and $25.00 check for application fee and first year dues to:

3679 Motor Avenue, Suite 205
Los Angeles, CA 90034

For information, assistance, or to request other application materials, or to submit application by email please contact the IPSA Membership Chairperson