International   Association of   Laryngectomees

Box 691060   Stockton, CA   95269-1060   Phone: (866) 425-3678   Fax: (209) 472-0516   Email: jhenslee@comcast.net

In accordance with Article IV, Section A, the IAL will recognize Associate Memberships to suppliers, manufacturers, health care, and service companies that provide medical support to laryngectomees. These members will have no voting rights but they may participate as committee members if requested. As an Associate Member you will be listed as such in the IAL Directory, and to where selective IAL correspondences will be sent. The current annual dues are $150 a year.

Company Name________________________________________________________________

Address _____________________________________________________________________

_____________________________________________________________________

City _________________________________________________________________

State/Country _______________________ Postal Code_________________________

Telephone _______________________ Email_________________________________

I apply for membership as an Associate Member of the IAL, and as such will be entitled to include the designation "IAL Associate Member" in my promotions.

Signed:_______________________________________ Date:____________________

Please sign above and mail your payment of $150 to:

International Association of Laryngectomees
P O Box 12036
Jacksonville, NC 28546