The information provided below may be listed in the IAL Directory, and to determine where selective IAL correspondences will be sent. Please complete fully and type or print all entries.

Name________________________________________________________________

Address _____________________________________________________________________

_____________________________________________________________________

City _________________________________________________________________

State/Country ______________________________ Postal Code__________________

Telephone ____________________ Email____________________________________

The IAL Bylaws provide that laryngectomees, significant others, speech professionals, and health care professionals who reside in a remote area, or in an area that can’t support an IAL Club, may join the IAL as a Member At Large. Members At Large will be assessed annual dues at a rate that is one-half that of the smallest club’s rate. These members may not serve as delegates at the Annual Meeting, or be elected to any office since these functions require the endorsement of an IAL member club.

Signed:_________________________________________ Date:___________________

Please sign above and mail your payment of $10 to:

IAL
925B Peachtree Street NE, Suite 316
Atlanta, Georgia 30309