PLEASE PRINT THIS FORM OUT, FILL IN YOUR INFORMATION, AND SEND TO NCEA.

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*  MEMBERSHIP APPLICATION *
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Please check appropriate box or boxes:

__ Individual NCEA Membership -- $149
__ Institutional NCEA Membership -- $315
__ Local Affiliate NCEA Membership-- $95
__ Associate Membership -- $60
__ (Special rate of $35 available to full-time students.)
__ District Advisory Council Membership -- $100
__ Member Emeritus -- $60

Indicate form of payment:


My check, payable to NCEA, is enclosed.

(International applicants pay in U.S. dollar equivalent.)
Please charge to my credit card:

VISA # __________________________ Exp. Date ____________

 
MasterCard #_____________ Exp. Date ___________

CVV# (3 digit code) ______

Signature ______________________________________________

(All charge orders must be signed.)


Please check the category that best describes your role in community education:

 __ Community school practitioner
 __ Adult/continuing education agency personnel
 __ Park and recreation agency personnel
 __ 21st Century/Afterschool Personnel
 __ Social service agency personnel
 __ University-college personnel
 __ Community/junior college personnel
 __ College student/intern/graduate assistant
 __ State education agency personnel
 __ Community council/neighborhood organization member
 __ School board/city-county commission member
 __ Elementary-secondary teacher
 __ Elementary-secondary principal
 __ School superintendent/administrator
 __ Other


Name _____________________________________________________

Title/Position ___________________________________________

Institution/Agency/Department ________________________________________________

Sreet Address ________________________________________________________________

City, State, Zip _____________________________________________________________

Daytime Phone (   )_________________________________

Fax ______________________________

Email Address __________________________________

Recruited by _______________________________________


Institutional Members: The person listed above will receive a subscription to
all publications and will be the voting member. Please list here the other two
persons who are to receive subscriptions to Community Education Journal and
Community Education Today.


2nd Subscription

Name&Title/Position __________________________________________________________

Address&City&State&Zip _______________________________________________________

Daytime Phone (   )_________________________________

Fax ______________________________

Email Address __________________________________



3rd Subscription

Name&Title/Position __________________________________________________________

Address/City/State/Zip _______________________________________________________

Daytime Phone (   )_________________________________

Fax ______________________________

Email Address __________________________________


National Community Education Association
3929 Old Lee Highway Suite 91-A
Fairfax, VA 22030-2401
Telephone (703) 359-8973
Fax (703) 359-0972