_______________________________________________________________________________________________________________________
Last Name                               First Name                              Middle Initial                          Business Phone                       Home Phone

_______________________________________________________________________________________________________________________
Business Address

How many years of accounting experience have you had? ___________ Date of Birth ______________________________________

Sole Practitioner [            ]                       Partner [             ]                   Employee  [             ]                        Corporate Officer  [             ]

Name of Firm ____________________________________________________________________________________________________________

Name of Partner(s) ________________________________________________________________________________________________________

________________________________________________________________________________________________________________________

Are you a Licensed, Registered or Certified Public Accountant? ______________ If yes, give License # ____________________________________

Are you an Accredited Public Accountant? ___________________  If yes, give accreditation # ___________________________________________

Are you an Enrolled Agent? ___________________ If yes, give EA # _______________________________________________________________

Do you hold an associate or baccalaureate degree with a minimum of 24 semester hours in Accounting?       Yes _____________ No ____________

Are you engaged in any other trade or profession? _________________ If yes, please describe __________________________________________

_______________________________________________________________________________________________________________________

Please list other accounting organization in which you hold membership:

________________________________________________________________________________________________________________________  

________________________________________________________________________________________________________________________

I hereby state that the accompanying statements are correct to the best of my knowledge and belief.  I further state that I will abide by the Constitution and By-Laws of the Society and will practice in strict conformity with the Code of Ethics and Rules of Professional conduct adopted by the Society.

Date ___________________________  Signature of applicant  _____________________________________________________________________

Annual dues are payable IN FULL in advance and are prorated for credit by ASPA on a monthly basis to August 31 –  the end of ASPA fiscal year.

[       ] Membership Annual Dues $85.00                   [       ]  Firm Annual Membership $50.00                 [       ] Diamond State Annual Dues $15.00

                                                                                                                                                               (Non-Residents only)

IMPORTANT NOTICE 
A copy of your professional stationary or business card MUST accompany this application unless you are applying for the Diamond State membership.

State Member approving membership:

_________________________________________

                         Signature                                                                       Title                                                  Date

__________________________________________        ________________________________________      _______________________

Sponsor, If any

FOR ASPA OFFICE USE

                    Amount                                                             Date Received                                                          Control number

“State Society dues payments may be deductible as on ordinary and necessary business expense.  However, they are not deductible as charitable contributions for Federal income tax purposes.”

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