USPA Membership Registration

(Step #1)

Please fill out the form below. This is the first step in the registration process.
The information below is collected for USPA's records. It is also used to match you against
the online membership purchase made in step two, through PayPal.

Please note: a PayPal account is not needed to purchase membership. Look for guest payment options under the default account login section.

If you have any questions, please contact webadmin@uspermafrost.org

Personal Information Check marks indicate required fields
Name :
Email Address :	Phone Number :	Fax Number :
Address :
City :	State : Non US - Intl Alaska Arizona Arkansas California Colorado Connecticut Delaware District of Columbia Florida Georgia Hawaii Idaho Illinois Indiana Iowa Kansas Kentucky Louisiana Maine Maryland Massachusetts Michigan Minnesota Mississippi Missouri Montana Nebraska Nevada New Hampshire New Jersey New Mexico New York North Carolina North Dakota Ohio Oklahoma Oregon Pennsylvania Puerto Rico Rhode Island South Carolina South Dakota Tennessee Texas Utah Vermont Virginia Washington West Virginia Wisconsin Wyoming	Zip Code :

For International Registrations
I would like to register as an international member
State/Province :	Country :	Postal Code :

Membership Options
Membership Type	Membership Years
Student Membership: $10 / year Individual Membership: $30 / year Sustaining Membership: $250 / year Lifetime Membership: $1000 Ice Vein Membership: $100 / year Ice Wedge Membership: $300 / year Massive Ice Membership: $1000 / year	2018     2019     2020
Additional Membership:	Membership Years
None Student Membership: $10 / year Individual Membership: $30 / year Sustaining Membership: $250 / year Lifetime Membership: $1000 Ice Vein Membership: $100 / year Ice Wedge Membership: $300 / year Massive Ice Membership: $1000 / year	2018     2019     2020

Additional Support (Donations)
Annual Meeting Sponsor	Permafrost Engineering Educational Program (PEEP)
Permafrost Young Researchers Network Educational Fund	UAF Educational Fund
Other

Professional Information ( If applicable )
Job Title :	Profession :
Employer :	Employer Affiliation : Federal State Other Government University Private Org. Private Citizen Business Self-Employed Volunteer Other

Corporate and Institutional Information ( If applicable )
Representative Contact Name:	Representative Contact Phone :
Representative Contact Email :

Student Information ( If applicable )
Name of College or University:	Degree Program
	BS MS PhD Other
Anticipated Graduation Date:
( MM/DD/YYYY)

Volunteer Opportunities
Would you be interested in serve on a committee?	Would you be willing to serve as a USPA officer?
No Thanks Educational Workshops Awards Committee Fundraising Committee By-Laws Committee Website Committee	No Thanks Vice President, President-Elect Secretary Treasurer Board Member