MEMBER INFORMATION

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* 1. PLEASE COMPLETE THE INFORMATION BELOW

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* 2. EDUCATION - highest level of education

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* 3. EMPLOYMENT

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* 4. I CONSENT TO HAVE MY NAME CONSIDERED FOR APPOINTMENT/ASSIGNMENT TO THE FOLLOWING POSITIONS.

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* 5. Please give a brief summary of your experience and/or interest in serving in position(s) selected above.

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* 6. If appointed to the IASN Board of Directors, it is my obligation to attend meetings and do the work of the position. If I am unable to fulfill this commitment, I will resign.

Completion of the line below serves as the electronic signature of the individual completing this form.

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