Membership Application - The International Childbirth Education Association

Membership Dues

Your Dues Rate Type is: Advocate Member

Contact Information Contact Information

Email *

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Prefix

First Name *

Middle

Last Name *

Suffix

Title

Informal Name

Company

Address 1 *

Address 2

Address 3

City *

State

Zip Code *

Country

Website

Phone Number *

Fax Number

CCMail

Include me in Membership Directories *
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Include me in Broadcast Email *
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Username/Password Username/Password

Please enter the Username/Password you would like to use to login to this website.

Your Username must be unique and must be at least 6 characters.
Passwords must be a minimum of 8 alpha-numeric characters with at least 1 number or 1 letter.

Username *

Password *

Confirm Password *

Additional Options Additional Options

Select additional contact types to include as part of your membership:

Advocate: Country Category A - $95.00

Advocate: Country Category B - $17.00

Advocate: Country Category C - $6.00

Advocate: Country Category D - $1.00

Payment Details Payment Details

Comments or Questions

Amount to Charge :

Payment Method:

Enter the name on the bank account according to the information shown on your bank statement. The account number and routing number can be copied from the lower left corner of the check.

Bank Name:
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Account Number:
Account Type:

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Card #:

Expires:

CSC (What's this?):

Enable Automatic Renewals?

Select "Yes" in order to be enrolled in automatic membership renewal. The above payment method will become your saved payment method, overwriting anything that may have been previously saved and will be used for future renewals. You can change the automatic renewal setting or saved payment method at any time in either the "Payment Method" or "Membership Auto-Renewal" tabs where you edit your profile.

No Yes