Name: (Last)___________________________ (First)_______________ (MI)____  Date of Birth:_______

Address:________________________________ City___________________ State:______Zip:_______

Country (if other than USA):_________________________

Home telephone: ________________________ E-mail address: _________________________________

Occupation: _______________________________

Please circle the highest education level attained:
High School    Trade School     Jr. College     College     Post Graduate   Other: _______________________

Please specify major field of study:_______________________________________________________

Other fields of specialized training:_______________________________________________________

Do you belong to any other UFO/Paranormal organizations ? (please specify)

___________________________________________________________

Have you investigated any anomalous activity or researched a particular area?

____________________________________________________________

What is your area of interest regarding anomalous phenomena? (circle appropriate category)
(NOTE: If you select a category other than "General Interest," please furnish information as to why you consider yourself qualified for that area, including what you have done to date.)

General Interest     Investigation     Research     Consultant  
Other (explain)_____________________________________

Signature: (required)______________________________________________ Date: ______________

Under 18 yrs of age, signature of Parent or Guardian:_____________________________ Phone:___________________

IMPORTANT:
___Check here if you wish your membership information to be shared with the other members.
___Check here if you do NOT wish to share ANY enrollment information with the other members.
___Check here if you wish only certain information be shared, and specify in the comment section below.

Annual membership dues ( U.S. currency):*       U.S.A.: $15     North America: $20     All other locations: $25

  *Additional individuals residing in the same household may become a member for ½ the normal annual dues.
    Separate applications must be filed for each person, and only one newsletter will be sent per household.

Please send this application, along with your check in the appropriate amount, to:
Independent Researchers' Association for Anomalous Phenomena, P.O. Box 12233, Albany, NY 12212-2233

Use this space for further comments (continue on reverse, if necessary):