*First Name: 

*Last Name: 

Title: 

*Business Email: 

*Business Phone Number: 

Mobile Number: 

Employer: 

*Business Address: 

*Street:

*City:  *State:  *Zip: 

Mailing Address:  (if different from business address):

Street:

City:   State:  Zip: 

Are you a current member of ASTD national?  Yes    No

If yes, what is your member number? What is your expiration date?

Interested in Presenting?

Interested in Volunteering?

Share Info with Others?   We plan to publish a on-line member directory soon!