AJKAT Membership Form

Member Record Maintenance

The membership list is strictly confidential, and will not be disclosed to anyone or any agency
outside the AJKAT Membership Committee without your prior notification and consent.
It will only be used for member benefits, verification (if desired),.and your membership card.

Prefix:

First Name: *

Last Name: *

Phone Number: *

E-mail Address: *

Street Address:

Address Line 2:

City:

State:

Postal Code: *

Country: *

Gender: *

Female
Male

Age: (approximate)

Occupation

Area of interest

Representative(s) To Visit

* Required Create Email Forms

I hereby submit my above information
for membership in AJKAT

You may place AJKAT logos on your web site upon Membership approval.

1629 K Street, NW Suite 306, Washington, DC 20006 202-221-5022 Fax 202-318-2503 info@AJKAT.org

Please donate to the new
independent WTC dust study

Return

(OFFICE USE ONLY)

Approved _____ Disapproved _____ Date ____________ Reviewed By: ______________

Comments: ________________________________________________________

__________________________________________________________________

AJKAT Membership Form

Member Record Maintenance

I hereby submit my above information for membership in AJKAT

Please donate to the new independent WTC dust study

Return

I hereby submit my above information
for membership in AJKAT

Please donate to the new
independent WTC dust study