COAA MEMBERSHIP REGISTRATION

NAME (English):        _________________________________________________________________
                                            First                                      Middle Initial                              Last

(Chinese - If available):
                                      _________________________________________________________________
                                            Last                                                              Given

ADDRESS (Home):    _________________________________________________________________
                                            Street

                                     _________________________________________________________________
                                            City                          State                      Zip                              Country
                  (Office):
                                     _________________________________________________________________
                                            Street

                                     _________________________________________________________________
                                             City                          State                      Zip                              Country

TELEPHONE:             _________________________________________________________________
                                            Home                                                   Office

FAX:                            _________________________________________________________________
                                            Home (Option)                                      Office

EMAIL ADDRESS:    _______________________________            _________________________
                                            Home (Option)                                                        Office

EMPLOYER:                _________________________________________________________________

FIELDS OF INTEREST OR SPECIALTY:
                                   
                                     _________________________________________________________________

COAA SPONSOR (Option):
                                     _________________________________________________________________
                                              First                                          Middle Initial                              Last

SIGNATURE:             _________________________________________________________________
                                                Signature                                                                              Date

Please send your registration with membership due (no cash) payable to COAA to:

COAA
P.O. Box 4948
Silver Spring, MD 20914-4948, U.S.A.

This page was last revised 11/21/2000