Please fill out the following information as thoroughly and clearly as possible, complete names cities, phone #s, etc.
This information is crucial for data capture and will be kept confidential.

• Print this web page,
• fill in,
• then mail Application & Check to the National Council Treasurer,
• Cynthia Tinsley, PO Box 83400 Conyers, GA 30013

Check one of the following: 

[] New Membership     [] Renewal     [] Update     [] I.C.A.E. Information Only

If this is a Renewal or Updated Information-Enter Your Membership Number: _______
Name:________________________________Job Title/Position:_________________________
AT&T Entity/Division:____________________________________________________________
Work Address:__________________________________________ Room Number:_____________
City:________________________________________ State:_____________ ZIP:___________
Work Phone:(   )____-_______ Ext:_______ E-Mail ID:______________________________
  

Where would you like the ICAE Information Sent: [] Home [] Work

Home Address:__________________________________________ Apt. #:__________________
City:________________________________________ State:_____________ ZIP:___________
Home Phone:(   )____-_______   E-Mail ID:_________________________

Have an interest in participating on a Committee or Sub-Committee?
Below are a few listed; specifiy if interested:

[] By-Laws       [] Communications      [] Conference Planning     [] Scholarship Committee
[] Elections     [] Membership          [] Public Relations
[] Other:________________________________________________________________________
Interests/Hobbies:_______________________________________________________________
_________________________________________________________________________________
  

Optional:

Heritage Information:____________________________________________________________

Applicant's Signature:____________________________________ Date:_________________
  

Annual Contribution: $25.00
MAKE CHECKS PAYABLE TO: ICAE

Date Recieved:__________  New Membership (Y/N):_____  Membership Number:__________
Received Amount of: $__________  Check:_____  Other:_________ Exp. Date:__________
Dues for: Nat'l:_____ Local:_____ Date Sent Local Dues:________ To:_______________
Date Sent to Data Entry:_____ Date Received by Data Entry:_____ By:_______________
Notes:




     

AT&T Proprietary Information

Print this web page, fill in, then mail Application & Check to the National Council Treasurer, Cynthia Tinsley, PO Box 83400 Conyers, GA 30013