PRINT, COMPLETE AND RETURN WITH YOUR $10.00 FEE TO.....

AAAI   /   P. O. BOX 660505 BIRMINGHAM, AL 35266-0505

Name: _______________________________

Address: _____________________________

                _____________________________

Occupation: __________________________

Employer : ___________________________

E-Mail: ______________________________

Phone: ______________________________

             (W)___________________________

IAAI No: _____________ Expires: __________