Fillable ICAN-USA MEMBERSHIP APPLICATION FORM

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ICAN-USA MEMBERSHIP APPLICATION FORM

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The ICAN-USA MEMBERSHIP APPLICATION FORM form is 2 pages long and contains:

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  • 3 check-boxes
  • 35 other fields

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ICAN-USA
Phone Number: 214-621-0965
Email Address: chairman@ican-usa.org
MEMBERSHIP APPLICATION FORM
First Name
PERSONAL INFORMATION
Middle Name Last Name
Firm or Company
Title
Birth Date Marital Status Married Single Gender Male Female
Home Address
Street Address
City State Zip
Phone or Fax Number
Zip State
Phone or Fax Number
City
Street Address
Business Address
Email Address
Preferred Mailing Address Home Address Business Address
MEMBERSHIP INFORMATION
ICAN Membership Number (if applicable)
CPA – State of Certification License Number Other
Other:
DUES
REGULAR MEMBER DUES: $100.00 (Check if applicable)
FELLOW MEMBER DUES: $100.00 (Check if applicable)
NEW MEMBER REGISTRATION FEE: $30.00 (Applicable to all)
OTHER $100 ICAN-NG-DUES
ICAN-USA
Phone Number: 214-621-0965
Email Address: chairman@ican-usa.org
MAILING INFORMATION: Mail completed application to:
ICAN-USA District Society
4225 Telegraph Avenue
Oakland, California 94609-2407
OR
Email scanned form to Chairman@ican-usa.org
No application will be processed without payment. Please include payment information in the following section.
PAYMENT INFORMATION
A) My check for $ payable to ICAN-USA is enclosed.
B) Direct Deposit in the amount of $ has been made to Bank of America ICAN-USA Society Acct 004612906996
(opened in MA). (Attach or fax a copy of the deposit slip)
C) Please bill my credit card: (Currently not available, Please use PAYPAL through www.ican-usa.org)
APPLICANT STATEMENT
To the best of my knowledge and belief, the information contained herein is true and correct. I agree to abide by the
decisions of board of directors as to the disposition of this application. If admitted as a member, I agree to be governed by
and to comply with the Bylaws and Code of Professional Conduct of the Institute.
We have reviewed and approved this application.
Name Title Date
Date Title Name
FOR OFFICIAL USE ONLY
Name Date
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ICAN-USA MEMBERSHIP APPLICATION FORM

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Completed 2 February 2022

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