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            HODIC Membership Application

Date:

Name:

Employer or School Affiliation:

Group & Title or Academic Dept. & Year:

(anticipated graduation or comletion date:)

Business or School Address:


Telephone:

Fax:

Home Address:


Telephone:

Fax:

Field or Academic Major:

E-mail Address:

Academic Society Memberships:

Mailing Preference (check one)
  Please send HODIC mailings to my
  ( ) Business/School Address   ( )Home Address