IMGCA Offline Membership Application

This is the form for applying for IMGCA membership by mail, with payment by check. If you prefer to pay online using your credit card or PayPal account, go to our Online Membership Application Form.

Please print this page or copy it into your word processor, fill it out and mail it to IMGCA, 39116 Fremont Hub #1303, Fremont, CA 94538 United States . Please include your check payable to IMGCA.

A star to the left of an item indicates a required entry.

*		Name ______________________________________
*		Choose a membership type (prices listed are for annual membership): Professional ($40)___ Student ($10)___ Volunteer ($40)___ Parent ($20)___ Institutional ($100)___ Affiliate ($60)___
*		Membership Length:
		One year___   Two years___   Three years___
*		Male___   Female___
		Date of birth __________________________________
*		Work address _________________________________
*		Work phone __________________________________
*		Email address ________________________________
		Alternate email address ________________________
		Home address ________________________________
		Home phone _________________________________
		Academic status ______________________________
		Occupation __________________________________
		Research interests:
		Do you want to be included in the IMGCA member directory on the web site?  Yes___   No___
		I have read and agree to the terms and conditions of IMGCA membership and to the terms and conditions of using the IMGCA web site.

Privacy notice: The information submitted on this application is used only for IMGCA purposes. At no time will we share any of this information with any other person or company.

Office Hours: Monday-Friday, 10am-6pm PST. Closed weekends and holidays.
Private backrooms in the IMGCA membership and certification areas are open 24-7, 365 days a year.

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