Association of VA Audiologists

Contributing Member Voluntary Dues - Membership Year 2009

October 1, 2008 through September 30, 2009

Date:    (mm/dd/yyyy)

Last Name*:       First Name*: 

Station:             VISN: 

Mailing Address:  Street:* 

                                 City:*        State:*    Zipcode*: 

Home Phone:   

Office Phone:   

Home e-mail*: 

Office e-mail:    

*denotes mandatory fields for processing

After completing, please print this page and send it with a check  for $45.00 payable to CHEP to:

Karen Stewart,  Au.D.
Audiology (112A)
Austin Outpatient Clinic
2901 Montopolis Drive
Austin, TX 78741

Please included a SASE so an AVAA Contributing Member Membership card and receipt can be sent.

The AVAA, as an organization under the umbrella of the AFASLP,  is recognized by the IRS as a 501(c)6 organization.  Voluntary dues payments are not deductible as charitable contributions.  They may be deductible as a business expense. Please consult your tax advisor for further information.