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Membership Application

Contact Information (fields with a * are required)

Member Type:

Name:


Prefix	First *	MI	Last *	Suffix

Nickname:

Title:

Email: *

Website:

Daytime Phone: *

Extension:

Fax:

Home Phone:

Unit:

Chapter:

School/Organization Name
(only if using school/org. address):

Street Address or
P.O. Box and Number: *

Suite/Room
(if applicable):

City: *

State/Province
(Required for US and Canada):

Zip/Postal Code
(U.S. ONLY): *

Country: *

CEC Member Profile

CEC uses the information from the member profiles to develop products and services to meet the needs of our members. You are encouraged to keep your profile up-to-date. Participation is voluntary. Thank you!

Your Professional Role:
(choose up to two)

Current Employment Setting:
(choose up to two)

Area of Interest/Specialization:
(choose up to two)

Age Level Served:
(choose up to two)

Personal Ethnicity:
(choose up to two)

Personal Disability:
(choose up to two)

Birth Year (yyyy):

Web Site Login:

E-mail Address: *

New Password: *

Verify New Password: *

Questions? Please contact the Constituent Services Department at (888) 232-7733
or service@cec.sped.org.