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Member Registration
First Name:
Last Name:
Middle Initial:
Title:
Occupation:
Certified Child Passenger
Safety Technichian:
No
Yes
Certification Number:
Organization:
Address:
City:
State:
Zip Code:
Daytime Phone:
E-Mail:
Bill to (if different from above)
First Name:
Last Name:
Middle Initial:
Organization:
Address:
City:
State:
Zip Code:
(
Purchase orders accepted
.)
Please make your check or money order payable to Indiana University and mail to:
Automotive Safety Program
575 West Drive, Room 004
Indianapolis, IN 46202
Once payment of $100 for a two year membership is received, you will be sent your username and password by e-mail.
Comments:
575 West Drive Room 004 Indianapolis, IN 46202 USA
local tel:: 317..274..2977 tel:: 800..543..6227 fax:: 317..278..0399
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