Membership Form

Gender:	Male Female
Honorific:		Office:
First Name:	M.I.	Fax:
Last Name:		Home:
Use Pen Name:		Mobile:
Professional Title:	Expertise:
Organization:	Org. Type:
Address:	City: State:
Zip Code:	Province:
	Mail Country:

E-Mail:		Contact Me By:
Web Address:
Comments:

— World Media Association —
3600 New York Ave. NE • Washington, DC 20002, USA • Phone: (202) 636-3124, Fax: (202) 635-9227
media@wmassociation.com • www.wmassociation.com