A. REGISTRATION INFORMATION

Last Name _______________________________   First Name ______________________________   Middle Initial 

Title ____________________________________________________________________

City ______________________________  State/Province _____________  Zip/Postal Code _________  Country

Area Code(______)Phone# ______________ Ext. __________  FAX Number(_____) _______________________

E-mail Address ________________________________________________________________________

B. PAYMENT: Membership dues for 1999 is US $50.00  or Canadian $75.00 per person

C. OTHER INFORMATION

1. Are you currently a member of a Regional/Local Users Group(RUG or LUG

2. Would you like to be placed in contact with your closest LUG or RUG ?

3. Would you allow NAIUA to mail directly to you on behalf of a third party

NAIUA
PO BOX 310
Brooklyn
Queen's County
NS
Canada
B0J 1H0

Phone (902) 354-3575 Fax (902)354-3284
E-mail: mgmt@naiua.org

Please return application to: