A.   S. A.  Membership Application

Applicant Information

Last  Name:                                        

First  Name:                                      

M I:

Business  Phone:

Home Phone:

Cell:

Business Address:

City:

State:

ZIP Code:

Sole Practitioner:              

Partner:

Employee:

Corporate Officer:

Name of Firm::

Name of Partner(s):

Are you a Licensed, Registered or Certified Public Accountant? : Yes   No

If yes, give License Nr:  #

Are you an Accredited Public Accountant? : Yes   No

If yes, give accreditation Nr:  #

Are you an Enrolled Agent? : Yes   No

If yes, give EA Nr:  #

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? : Yes   No

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:  12/15/2009                 TYPED Signature of applicant : X

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 $110.00   

 Firm Annual Membership $50.00 

 Diamond State Membership (Non-Residents only)  $15.00   

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

Do Not Write Below This Line

State Member approving membership:

 _

Signature:

Title:                                                  

Date:  _ _ / _ _ / _ _ _

Amount: $

Date Received:   

 _ _ / _ _  / _ _ _ _ 

Control Nr:  #