NALIP

IMA Membership Application

Contact Information
First Name *
Last Name *
Synod *

Address 1 *
Address 2
City *
State *
Zip Code *

Email *
Home Phone *
Office Phone
Cell Phone

Optional Information
Interim Training Level	No Training Discernment Basic Course Advanced Course

Roster	Associate in Ministry Clergy Diaconal Ministry Deaconess

Present Position

Task Forces I would be willing to serve (Check all that apply):	Membership Advocacy (with synods and congregations) Communications (newsletter and website) Other (list area of interest):

IMA Dues
2010 Membership Membership for 2010 - $60 Life Memberships Life Membership: Up to 55 years — $450 Life Membership: Ages 56–60 — $350 Life Membership: Age 61 + — $250

Please make sure all of your information is accurate before you click the button.

2011 Conference

To Be Announced