Influencing State Policy
Annual Membership Dues & Information Sheet
2008
(January to December)

PLEASE RETURN THIS FORM WITH YOUR ANNUAL MEMBERSHIP FEE FOR 2008 OF $25 (NO CASH) MADE PAYABLE TO INFLUENCING STATE POLICY (ISP) TO:

Influencing State Policy, Dr. Kathy Byers
Indiana University School of Social Work
1127 Atwater
Bloomington, IN 47405
phone (812) 855-4427
kvbyers@indiana.edu

The EIN number used by ISP is: 81-067-6553

Directions:  Please fill out the information below so that ISP will be able to communicate with you in an accurate and timely way. Your professional card may be attached to the form if it has all of the relevant information.

I wish to be listed as: ____Liaison    ____Friend of ISP  (check one)

NAME ____________________________________________

TITLE/OFFICE _____________________________________

ADDRESS (Univ. or agency)

 _______________________________________________________

Street/POB _____________________________________________

City, State, ZIP _______________________ ________  _________

TELEPHONE: (    )__________________________(OFFICE)

FAX: (   )_______________________________

EMAIL:  _________________________________________

If you have any questions about ISP, please go to our website at http://www.statepolicy.org or call Kathy Byers at (812) 855-4427 or email her at kvbyers@indiana.edu

Thank you very much for your support of Influencing State Policy!