INDIVIDUAL MEMBERSHIP APPLICATION FORM May 2009 - April 2010 NWO-SEM SLEEP SOCIETY (TAX  I.D.  20-2242551)
	Name __________________________ Degree/ Credentials_____________ Institutional Affiliation ______________________________________________ Already Member of             AASM             APT                   Mid-West APT             AARC Phone ______________________________   Fax _____________________________ E Mail ______________________________________________________________ Preferred Mailing Address ____________________________________________________ ________________________________________________________________________ Preferred Contact Method       Mail                           Fax                                     E Mail Annual Dues:  Full Member            25.00 USD     Complete this form in  full, and mail with Annual Dues (Payable to NWO-SEM Sleep Society by Check Only) to : NWO-SEM Sleep Society P.O. Box 167878 Oregon, OH 43616-7853.