Please TYPE or PRINT.

Name: ____________________________________________________________

Address: __________________________________________________________

City, State, Zip Code: ________________________________________________

Phone: _________________________   Fax: ___________________________

E-mail: ____________________________________________________________

Membership ID#:  _______________

Name of most recent employer: ________________________________________

Last date of employment: ____________________________

I AM APPLYING FOR (please check all that apply):

  DUES SUSPENSION
  AFP ANNUAL CONFERENCE SCHOLARSHIP*
 

*NOTE:
If a Career Trust member becomes re-employed prior to using the scholarship, its award will be at AFP's discretion.

Have you ever been an AFP Volunteer? If so, list all volunteer roles and terms in which you have served. [List on separate sheet(s).]

I affirm that all the information I have stated is true. I understand that membership is conditional upon the qualifications outlined by the Career Trust program. I understand that the information I have listed above is subject to verification by AFP. If I become re-employed within the calendar year of my dues suspension I agree to remit dues to AFP for the membership year.

Signature: __________________________________ Date: _______________