Directions: Print out this page, complete, and mail to the address below.

Annual fee is $45.

Name:

Discipline, Degree:

Address:

City, State, Zip Code:

Email:  (must be exact so PLEASE print legibly)

Web site:

Telephone:

Fax:

Mail completed form to:

Roz Heiko, PhD

531 Keisler Dr.  Suite 203

Cary, NC 27518