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Please print this form, complete it, and mail to:

Maureen Busta, ICTM Secretary
2382 Iowa Highway 24
New Hampton, IA 50659

ICTM
Membership
Application



MEMBER NAME:


Home Address:


 City:                                                                                     State:                    Zip Code:


Phone:


Email:


AEA #:                                                          School Name:


School District:

MEMBERSHIP FEES:

_____Regular Membership ( 1 year - $20, 2 years - $38, 3 years - $50)
_____Student Membership ($5)
_____Retired Membership ($5)  - (0$ if ICTM member for past 5 years)
_____Institutional Membership ($35)*

Donation   $ _________  Please specify use:      _____________________________

*Institutional membership for elementary schools

CHECK YOUR MAIN AREA OF INTEREST (only one):

_____Grades K-2

_____Grades 9-12

_____Library/Media

_____Grades 3-5

_____Post Secondary

_____Supervisor/Administrative

_____Grades 6-8

_____Special Education