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Application for Membership
Name: ________________________________________ Circle one Mr. Mrs. Miss Dr. Other
Title: __________________________________
School District: ____________________________________________________________________
Street Address: ____________________________________________________________________
City/State /Zip: _____________________________________________________________________
Telephone: _______________________________________________________________________
Fax: ____________________________________________________________________________
Email: __________________________________________________________________________
Affiliate Organization: (e.g. CASE, MECA, MASS, etc.) ______________________________________
$125.00 Individual Membership
$40.00 Retired Membership
$500.00 Lifetime Membership
Method of Payment:
- Check number ___________________ in the amount of ______________ enclosed
- Bill my district for purchase order number ___________________
- Charge my credit card number: _____________________________________________
- Visa
- MasterCard
- Discover Card
Expiration date: ____________________ Amount: __________________________
Signature: __________________________________________________________
Mail Registration To :
MASA
Post Office Box 326
Clinton , Mississippi 39060
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©MASA
Mississippi Association of School Administrators
Last Updated:
Designed by: Rick Smith
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