Application for Associate Membership

Name:

Preferred Mailing Address:

Office Phone(s):

Home Phone:

Additional Phone(s):

Email:

Please explain your interest in IPSA membership:

Educational Background

Institution and Field of Study:

Credentials, training, affiliations related to your interest in IPSA membership:

Number of years as a Surrogate (circle)   0             1-5             5-10              11-19             20+

Mail application and $25.00 check for application fee and first year dues to:

IPSA 3428 Motor Avenue
Los Angeles, CA 90034

For information, assistance, or to request other application materials please contact the IPSA Membership Committee (membership@surrogatetherapy.org)