Contact and Membership Information

Thank you for volunteering to serve APIC Indiana. Our Chapter cannot thrive without involved members like you! Please complete this survey so that APIC Indiana leadership can be aware of your willingness to serve. An APIC Indiana leader will reach out should you meet the needs of the Chapter.

Question Title

* 1. Contact Information

Question Title

* 2. Number of years as an APIC Member

Question Title

* 3. Number of years as an APIC Indiana Member

Question Title

* 4. APIC Identification Number

Question Title

* 5. APIC Membership Expiration Date

Date

Question Title

* 6. List previously held APIC Regional, State, or National offices:

Question Title

* 7. List other applicable professional organization memberships:

T