Name:		______________________________________________________________
    

Institution:	______________________________________________________________


Mailing Address:______________________________________________________________

		______________________________________________________________
                                                
		______________________________________________________________


Office Phone: (   ) ___________ Home: (   ) ___________ FAX: (   )____________


E-mail Address:	______________________________________________________________

Scholarly Interests (one or two sentences for our membership roster):

______________________________________________________________________________
     
______________________________________________________________________________
     
______________________________________________________________________________


SIG membership dues of AERA members must be paid directly to AERA.  Current
AERA members should renew SIG membership at time of AERA membership renewal.
New AERA members should request SIG membership when joining AERA. 

Membership dues of non-AERA members should be paid to the SIG at the rates
indicated below. Please make check payable to: AERA REAPA SIG. (Please do not
send cash.)
 
	Type of Membership (non-AERA members only):  

                   		1-year	2-years	3-years

		Regular:	[] $7	[] $12	[] $15

		Student:	[] $5	[]  $8	[] $10


Questions may be addressed via e-mail to: ciwamoto@mail.nbme.org 
Please send completed application and dues (non-AERA members only) to:
                
	Carrolyn Iwamoto, Treasurer, SIG-REAPA
       	National Board of Medical Examiners
       	3750 Market Street
       	Philadelphia, PA  19104
       	Phone:	(215) 590-9752
       	Fax:	(215) 590-9437