Associate Member Application

Application for Associate Membership


Name:

Preferred Mailing Address:

Office Phone(s):

Home Phone:

Additional Phone(s):

Email:

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:

IPSA
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