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Registration Form

NAME (INCLUDE TITLE): *
HOME ADDRESS: *
HOME PHONE: *
E-MAIL ADDRESS: *
S’MICHA:
SYNAGOGUE AFFILIATION:
PRIMARY PROFESSIONAL FIELD:
WORK ADDRESS:
WORK PHONE:
EMPLOYER:
HIGHEST DEGREE EARNED:
FIELDS OF EXPERTISE OR INTEREST:
DUES SCHEDULE *	Lifetime Membership $1000 Annual Membership $100 Student Membership $50 Spouse Membership $25 General Membership
PAYMENT OPTION	Credit Card

CREDIT CARD TYPE	VISA MASTERCARD AMERICAN EXPRESS
CREDIT CARD NUMBER *
NAME AS APPEARS ON CREDIT CARD:
EXPIRATION DATE:	Month 1 2 3 4 5 6 7 8 9 10 11 12 Year 2006 2007 2008 2009 2010 2011 2012

Would you like to actively participate in AOJS by:
Speaking at a future AOJS event?		(Check box for "Yes")
Moderating at a future AOJS event?
Submitting essays or articles to any of the various AOJS publications?
Volunteering to help arrange, organize or assist in AOJS functions or services?
* Required Fields