Please choose one:*
	--Please Select--Dr.Ms.Mr.

	Member Information:*
	Name (First Last)   Position   District   County   Address   City   State   Zip Code   Work Phone (xxx)xxx-xxxx   Work Phone Ext.   Fax   Email Address   Year appointed to present position

	Home Address:*
	Address   City   State   Zip Code   Home Phone (xxx)xxx-xxxx   Birth Date (Mo./Date/Year)

	Please provide your 2012-2013 Year Salary on the line below:*

	STEP 1 of 2 Please complete the Dues Calculation below and list the sum on the line provided below. .01 x 2012-13 Salary to nearest $5 = (minimum dues $785)*

	STEP 2 of 2 Total NJASA Dues = Total Sum From Above + $200 *

	Please choose your payment method below:* For additional payment options or questions, contact Charlotte Duthie, Membership/Office Manager at 609-599-2900 ext. 127 or email cduthie@njasa.net. A portion of your dues relates to lobbying and is not tax deductible.
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