ASTD Nebraska Membership Application

Welcome to ASTD Nebraska. Please complete the following form fields. This membership information also becomes your online profile. When you have completed this form, use the submit button at the bottom of the page to complete your membership application.

If you are completing a membership for a renewing member you will need their membership ID number to complete the application.

Below is a short description of our Membership Levels. You will be able to select the best one for you at the bottom of the form.

Membership Type	Description	Cost
Classic	ASTD Nebraska Membership	$50.00
Classic Plus	ASTD Nebraska Membership & ASTD National Memberships	$219.00
Student	ASTD Nebraska Membership (must be enrolled for 12 credit hrs.)	$25.00
Student Plus	ASTD Nebraska Student & ASTD National Memberships	$84.00
Senior	ASTD Nebraska Membership (must be 62 years or older)	$35.00
Senior Plus	ASTD Nebraska Membership & ASTD National Memberships	$125.00


Section 1: User Information
First Name*

Last Name*

Initials

Company*

Position Title*

Mailing Address*

City*

State*

Zip Code*

Country

Work Phone*

Home Phone

Mobile Phone

E-mail*

User Name*

Functional Title*

Address 2

Address Type*

E-mail 2*

Web Site

Web Site 2

Hide in Search

Yes No

Hide Address

Yes No

Hide Email

Yes No

Hide Phone

Yes No

DOB

Gender

Spouse

Willing to Serve on a Committee?

Board Member?

Board Title, if applicable

New Member?


Section 2: Additional Addresses
Same as Primary Address

Address

Address 2

City

State

Zip Code

Address Type


Section 3: Membership Information
Referred By ASTD Nebraska Member

Referred by Other

Certifications

Work Experience

Areas of Expertise

Industry

Selection Not Available

Size of Company

Referral Source

Section 4: Membership Type

Membership Type*

	$219.00 - Classic Plus: ASTD Nebraska membership & ASTD National membership When joining ASTD National, please use our CHIP Source Code: CH6064. Our Chapter receives credit for your application.
	$125.00 - Senior Classic Plus (Age 62+): ASTD Nebraska membership & ASTD National memberhsip
	$84.00 - Student Plus: ASTD Nebraska Membership & ASTD National Membership (undergraduate students must be enrolled in a minimum of 12 credit hrs.; graduates students, 6 credit hours* *When joining ASTD National, please use our CHIP Source Code: CH6064. Our Chapter receives credit for your application.
	$50.00 - Classic: ASTD Nebraska membership
	$35.00 - Senior (Age 62+): ASTD Nebraska Senior memberhsip
	$25.00 - Student: ASTD Nebraska Membership undergraduate students must be enrolled in a minimum of 12 credit hrs.; graduates students, 6 credit hours)
	$0.00 - Presidential: ASTD Nebraska Chapter Past Presidents


Section 5: Payment
Payment Method* Credit card Send invoice

Section 6: Education History

Enter your Education History

School:		Degree:
Major:		Year Graduated:

School:		Degree:
Major:		Year Graduated:

School:		Degree:
Major:		Year Graduated:

School:		Degree:
Major:		Year Graduated:

Section 7: Career History

Enter your Career History


Company Information:
Name:
Description:

Position Information:
Title:
Description:
Start Date:		End Date:

Company Information:
Name:
Description:

Position Information:
Title:
Description:
Start Date:		End Date:


For security reasons, type in the code below:

ASTD Nebraska | (402) 850-6710 | P.O. Box 8273 Omaha, NE 68108

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