Application Type? New Renewal

First Name: 

Last Name: 

CPM? CPM Associate CPM

Title: 

Agency/Organization:       

Mailing Address: 

City:       State:  AL AK AZ AR CA CO CT DE FL GA HI ID IL IN IA KS KY LA ME MD MA MI MN MS MO MT NE NV NH NJ NM NY NC ND OH OK OR PA RI SC SD TN TX UT VT VA WA WV WI WY

Zip Code: 

Work Phone: 

FAX: 

Email: 

Home Phone:

Cell Phone:

Highest CPM Level Completed:

Certification Obtained From:

Certification Year: 2008 Select Year 2009 2010 2011 2012

Are you currently a Certified Public Manager®?  Yes No

Date Certified: 

Referred By:

Do you want to add a voluntary $5.00 Donation to the Susan G. Komen Foundation?  Yes No

• ASSOCIATE^*: $75 Annually (Completion of an Approved Supervisory Training Program or enrollment in CPM Program)

• MEMBER: $75.00 Annually (CPM status)

• RETIREE: $20.00 Annually (Reduced dues rate for all retired members who have CPM Status)

Please make checks payable to the Arizona Society of Certified Public Managers® , Inc. (ASCPM).  Membership Applications will not be valid until payment in full is received by the Society.

Please include verification of Supervisory Program or latest CPM course completion, or your CPM Certification with your check if a new member or if requesting a change in status from Associate to Full Member.

Make Checks Payable to:

Arizona Society of Certified Public Managers®, Inc.

Send Checks to:

ASCPM

P. O. Box 33744

Phoenix, AZ  85067-3744