Fillable APPLICATION FOR INTERNATIONAL AFFILIATE STATUS (American Speech-Language-Hearing Association)

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APPLICATION FOR INTERNATIONAL AFFILIATE STATUS (American Speech-Language-Hearing Association)

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American Speech-Language-Hearing Association
P.O. Box 1160 • Mail Stop 455 • Rockville, MD 20849-3289 U.S.A.
301-296-5700 • FAX 301-296-8582
www.asha.org
INSTRUCTIONS
• Please complete all information on this application. Each question must be answered.
• Payment to apply to become an International Affiliate can be paid using two options:
• (1) Bank-to-bank wire transfer — Review instructions/Complete Payment Information Form
• (2) Credit card payment — Complete Payment Information Form
• Please remit $90 in U.S. currency, which includes your annual dues ($75, U.S. currency) and your one-time application
fee ($15, U.S. currency) with your application. Your affiliation is based on a calendar year.
• Please indicate the degree or credential required to practice in the country in which you reside or for professionals
residing in countries without either a specified credential or the requirement of a degree to practice in audiology or
speech-language pathology, documentation must be provided indicating that she/he has worked as a professional
practitioner in one of these professions for a minimum of 3 years, accompanied by a letter of support from the minister of
health or person of authority in the country verifying the person’s functioning in this capacity.
• International affiliation is open only to persons who do not reside in and who are not exclusively citizens of the United
States. Dual citizens may also become International Affiliates as long as they reside outside the United States. If you are
a citizen of the United States exclusively, or if you are planning to move to the United States in the near future, you may
wish to apply for regular ASHA Membership.
• If you have questions concerning International Affiliation with the Association, please address them to: Membership,
American Speech-Language-Hearing Association, 2200 Research Boulevard, Rockville, MD 20850 U.S.A., or call the toll-
free Action Center line 800-498-2071 or email joinasha@asha.org
AFFILIATE PROFILE:
1. Name
(First) (Middle)
(Maiden) (Last)
2. Mailing Address:
(City) (Country) (Postal Code)
3. Email Address:
4. I am a citizen of:
(Country)
Dr.
Mr.
Miss
Mrs.
Ms.
APPLICATION FOR INTERNATIONAL AFFILIATE STATUS
1
5. EMPLOYMENT PROFILE:
Employer’s Name ___________________________________________________________________________________
Position/Title _______________________________________________________________________________________
Email _____________________________________________________________________________________________
Duties ____________________________________________________________________________________________
_________________________________________________________________________________________________
6. EDUCATIONAL PROFILE:
Please enter the recognized degree or credential in your country or residence.
University/Institution __________________________________________________________________________
Major Audiology Speech-language pathology Other: ___________________________________
Date of Degree (mm/dd/yy) _______________________
Degree Earned
BA BHS BS MA MS AuD PhD
Other (please indicate): ________________________________________________________________________
7. Please check the box below if your country does not have a recognized degree or credential and attach a letter of
support from the minister of health verifying your professional work.
Additional Information: _____________________________________________________________
_______________________________________________________________________________
_______________________________________________________________________________
_______________________________________________________________________________
8. DEMOGRAPHIC PROFILE:
Race/Ethnicity (optional)*
Which of the following best describes your ethnicity? (please check one):
Hispanic or Latino Not Hispanic or Latino
Which of the following best describes your race? Choose all that apply.
American Indian or Alaska Native Native Hawaiian or Other Pacific Islander
Asian White
Black or African American
*One of ASHA’s goals is to have its membership represent the multicultural diversity of our society.
Your completing this section helps us to accomplish this goal.
I certify that I do not reside in nor am I a citizen exclusively of the United States. Further, I certify that I hold the appropriate
degree or credential necessary for International Affiliation with the American Speech-Language-Hearing Association. And
further, I agree not to use my affiliation with the American Speech-Language-Hearing Association in the promotion of
commercial products.
_________________________________________________________________ _________________________________
Signature Date
2
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The ASHA Leader and Journals
Stay Connected — All members and affiliates receive The
ASHA Leader and unlimited access to all four of ASHA’s
online journals—the American Journal of Audiology: A
Journal of Clinical Practice; American Journal of Speech-
Language Pathology: A Journal of Clinical Practice;
Journal of Speech, Language and Hearing Research; or
Language, Speech, and Hearing Services in Schools.
www.asha.org
Access Anytime — ASHA’s award-winning website is
the largest online resource for audiologists and speech-
language pathologists. As an ASHA international affiliate,
you have password-protected access to members-only
content, including:
• Member Communities
• Research
• Journals
• Legislative Updates
• Networking opportunities with other audiologists and
speech-language pathologists
• And much more!
Continuing Education
Professional Development — ASHA provides a variety
of continuing professional education opportunities
including convenient self-study products, workshops
and conferences, and more than 1,400 opportunities to
earn CEUs at ASHA’s annual Convention. As an ASHA
International Affiliate you will also enjoy discounts on CE
products and services at ASHA’s online store.
Convention Discounts
Network — The annual ASHA Convention brings together
thousands of members, affiliates, educators, and exhibitors
annually. Members and affiliates are offered discounts
on all convention services, including registration, short
courses, institutes, and products.
Special Interest Groups
Grow and Learn — ASHA’s Special Interest Groups
(SIGs) are a great benefit, an outstanding professional
resource, and only available to ASHA and NSSLHA
members, Associates, and International Affiliates. For
only $45/SIG, receive access to all of SIGs’ online
periodicals Perspectives, network on your SIG’s exclusive
online discussion forum, earn professional development
inexpensively through self-study of your Perspectives, and
receive discounts on other ASHA-sponsored continuing
education events. With 19 SIGs, there’s bound to be at
least one for you. Examples include Global Issues in
Communication Sciences and Related Disorders (SIG 17),
Language Learning and Education (SIG 1), and Audiology
and Public Health (SIG 8). For more information, visit the
ASHA website at www.asha.org/SIG/join/
Product and Service Discounts
Save on Resources — ASHA has hundreds of products
tailored to the unique needs of members, affiliates and
certificate holders. Members and affiliates earn discounts
from 20 to 50 percent off regular prices for publications,
reference texts, consumer assistance materials, and more.
ASHA provides International Affiliates a wealth of benefits that can help you advance your career, keep in
touch with other professionals who share your interests, save money on products and services, and keep
abreast of the latest developments in your field.
Visit www.asha.org/ia for more information.
FOR MORE INFORMATION Contact the Action Center at 800-498-2071 or via email at joinasha@asha.org.
BENEFITS OF AFFILIATION
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1. Language Learning and Education
2. Neurogenic Communication Disorders
3. Voice and Upper Airway Disorders
4. Fluency and Fluency Disorders
5. Craniofacial and Velopharyngeal Disorders
6. Hearing and Hearing Disorders: Research and Diagnostics
7. Aural Rehabilitation and Its Instrumentation
8. Audiology and Public Health
9. Hearing and Hearing Disorders in Childhood
10. Issues in Higher Education
11. Administration and Supervision
12. Augmentative and Alternative Communication
13. Swallowing and Swallowing Disorders (Dysphagia)
14. Cultural and Linguistic Diversity
15. Gerontology
16. School-Based Issues
17. Global Issues in Communication Sciences and Related Disorders
18. Telepractice
19. Speech Science
YES, I WANT TO JOIN A SIG.
Check the special interest group(s) you wish to join:
To learn mo
re about each SIG, please refer to www.asha.org/SIG
NOTE:
Membership is on a calendar year basis. Those joining after August 31 will be affiliates for the succeeding calendar year, but
will be eligible for discounts at select Convention-related events for both years.
FEES:
Affiliate $45 × _______ ASHA Member, ASHA International Affiliate, ASHA Associate
Multiply the fee by the number of SIGs you wish to join.
Total: $____________
4
American Speech-Language-Hearing Association
P.O. Box 1160 #455
Rockville, MD 20849-3289
• ASHA accepts MasterCard, Visa or Discover charge cards.
• ASHA’s International Affiliate and Membership without Certification programs are based on a calendar year. Applications
received between September 1 and December 31 will be processed for the current year but will include membership
through the following year.
• Please submit payment in full, U.S. funds only, with your application.
• The maintenance of your membership is dependent upon payment of your annual dues and fees.
• If you have questions about your affiliation/membership, please contact the ASHA Action Center for assistance at
800-498-2071.
International Affiliate. Open to individuals who reside abroad and who are not exclusively
citizens of the United States. Dual citizens may also become International Affiliates as long as
they reside outside of the United States. Please send $90 U.S. currency, which includes your
annual dues ($75, U.S. currency) and your one-time application fee ($15, U.S. currency).
Your affiliation is based on a calendar year.
INSTRUCTIONS TO COMPLETE BANK TO BANK WIRE TRANSFER
• Contact joinasha@asha.org to receive wire transfer information.
• Once you have received the information, please complete the payment information form included with the application.
• Please submit payment in full, in U.S. funds only through your bank.
• Please include any fees that your bank charges to process the wire payment.
• Please include payment for Special Interest Groups (Optional). See attached SIG form to indicate which SIGs you are
joining.
• Include your full name on the wire transfer initiated by your bank.
• Please send your international affiliate application via mail, email, or fax at the same time that you submit your wire
transfer to ensure the application is available once the payment has been processed.
*All dues/fees payments are nonrefundable.
PAYMENT INFORMATION
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38165
Name of Applicant ____________________________________________________________________________________
Address _____________________________________________________________________________________________
City, State, Country, Postal Code _________________________________________________________________________
Email _______________________________________________________________________________________________
Suntrust Bank Transfer
for Annual Dues
Special Interest Group(s)
(optional)
Bank Transfer Fees Amount of Payment
$90 (U.S. Currency) ______ x $45 = ____________ $_____________ $_____________
This certifies that I,
_____________________________________________________________________________________,
submitted a wire bank transfer on ________________________ (date).
NOTE: To avoid a delay in payment processing, please check with your bank to ensure that your card can be used in the U.S.
Name of Applicant ____________________________________________________________________________________
Address _____________________________________________________________________________________________
City, State, Country, Postal Code _________________________________________________________________________
Telephone (please indicate cell/work/home) _______________________________________________________________
Email _______________________________________________________________________________________________
I wish to pay by: MasterCard VISA Discover
_________________________________________________________________ _________________________________
Account Number Expiration Date
____________________________________________________________________________________________________
Name of Cardholder (as it appears on card)
Annual Dues: $90
I would like to join a Special Interest Group(s) (optional) _____ x $45 each = $ ______________
Amount of Payment $ ___________________ (Please indicate amount you are authorizing to be charged.)
_________________________________________________________________ _________________________________
Signature of Cardholder Date
(For your security: DO NOT fax or email credit card information.)
PAYMENT OPTION #1: BANK TRANSFER
PAYMENT OPTION #2: CHARGE INFORMATION
6
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APPLICATION FOR INTERNATIONAL AFFILIATE STATUS (American Speech-Language-Hearing Association)

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Completed 27 August 2020

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