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Member Registration

First Name:
Last Name:
Middle Initial:
Title:
Occupation:
Certified Child Passenger
Safety Technichian:
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.

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