I am applying for the following membership category: (Check one)

Associate Academic
Associate CPA Firm Employee
Associate CPA Candidate
Associate Student
Associate International
CPA Member

First Name:
Last Name:
E-mail:
Please re-enter your e-mail:
Date of Birth:
Sex	M F
Are you a CPA licensed in New York?	Yes No
If yes, license number
Dated:
If no, in which state or political subdivision of the United States are you certified?
Out-of-State Certificate Number
Out-of-State Certificate Dated
Has your authority to practice any profession ever been suspended, revoked or limited, or have proceedings for such purpose ever been initiated against you?	Yes   No (If yes, fax or e-mail a written explanation)
College attended
Year will/graduated
Major/Degree
If applying for Associate International, name of Institute of Accountancy
When licensed
Certificate Number
I am not employed at this time. *Otherwise, please fill out your firm info below:
Business Affiliation
Work Address
Work City
Work State
Work Zip
Work General Telephone
Direct Work Telephone or Ext.
Work Fax
Work E-mail
Work Web Site URL:
Home Address
City
State
Zip
Telephone
Fax
E-mail
Where would you like your mail sent?	Work   Home
What is your professional class?	Sole Practitioner Partner Professional Corporation/Principal CPA firm staff CPA in industry CPA in education CPA in government
Where did you hear about the NYSSCPA?	Society publication Society member Society web page FAE event Other
Have you previously been a member of the NYSSCPA?	Yes No
If yes, when?
Do you presently subscribe to The CPA Journal?	Yes No
Are you a member of any of these professional organizations?	American Institute of CPAs Financial Executives Institute Institute of Management Accountants Other
What persuaded you to join the NYSSCPA?	Recruitment E-mail Recruitment Mailing Print Advertisement CPE Course Word of Mouth / Recommendation The CPA Journal The Trusted Professional