CAREI
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CAREI Membership Application

 
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*  
 Pager  
 E-mail*  
 User Name*  
 Password*
confirm password 		 
 E-mail 2*  
 
Section 2: Membership Information
 Referred By CAREI Member
 
 Member ID#  
 Referred by Other  
 Certifications
 
 
 Work Experience
 
 
 Areas of Expertise
 
 
 Licensed in State  
 
Section 3: Membership Type
 Membership Type*
 $279.00 - Academic Membership
$69.00 - Basic Yearly Membership
 
 
Section 4: Payment
 Payment Method*
    Credit card
 
 

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