Name Prefix Select Mr. Ms. Mrs. Miss Dr. Rev. First Middle Last Annotation Select Ph.D Jr. Sr. II III For Individual Members: Home Address Address Address City State   Select Indiana Alaska Alabama Arkansas Arizona California Colorado Connecticut D.C. Delaware Florida Georgia Hawaii Iowa Idaho Illinois Kansas Kentucky Louisiana Massachusetts Maryland Maine Michigan Minnesota Missouri Mississippi Montana North Carolina North Dakota Nebraska New Hampshire New Jersey New Mexico Nevada New York Ohio Oklahoma Oregon Pennsylvania Rhode Island South Carolina South Dakota Tennessee Texas Utah Virginia Vermont Washington Wisconsin West Virginia Wyoming   Zip Code   County for Indiana Residence   Select Marion Hamilton Johnson Adams Allen Bartholomew Benton Blackford Boone Brown Carroll Cass Clark Clay Clinton Crawfor Daviess De Kalb Dearborn Decatur Delaware Dubios Elkhart Fayette Floyd Fountain Franklin Fulton Gibson Grant Greene Hamilton Hancock Harrison Hendricks Henry Howard Huntington Jackson Jasper Jay Jefferson Jennings Knox Kosciusko LaGrange Lake LaPorte Lawrence Madison Marshall Martin Miami Monroe Montgomery Morgan Newton Noble Ohio Orange Owen Parke Perry Pike Porter Posey Pulaski Putnam Randolph Ripley Rush Saint Joseph Scott Shelby Spencer Starke Steuben Sullivan Switzerland Tippecanoe Tipton Union Vanderburgh Vermillion Vigo Wabash Warren Warrick Washington Wayne Wells White Whitley   For Corporate Members: Business Address Business Name Contact Person Address Address City State   Select Indiana Alaska Alabama Arkansas Arizona California Colorado Connecticut D.C. Delaware Florida Georgia Hawaii Iowa Idaho Illinois Kansas Kentucky Louisiana Massachusetts Maryland Maine Michigan Minnesota Missouri Mississippi Montana North Carolina North Dakota Nebraska New Hampshire New Jersey New Mexico Nevada New York Ohio Oklahoma Oregon Pennsylvania Rhode Island South Carolina South Dakota Tennessee Texas Utah Virginia Vermont Washington Wisconsin West Virginia Wyoming   Zip Code   County for Indiana Business   Select Marion Hamilton Johnson Adams Allen Bartholomew Benton Blackford Boone Brown Carroll Cass Clark Clay Clinton Crawfor Daviess De Kalb Dearborn Decatur Delaware Dubios Elkhart Fayette Floyd Fountain Franklin Fulton Gibson Grant Greene Hancock Harrison Hendricks Henry Howard Huntington Jackson Jasper Jay Jefferson Jennings Knox Kosciusko LaGrange Lake LaPorte Lawrence Madison Marshall Martin Miami Monroe Montgomery Morgan Newton Noble Ohio Orange Owen Parke Perry Pike Porter Posey Pulaski Putnam Randolph Ripley Rush Saint Joseph Scott Shelby Spencer Starke Steuben Sullivan Switzerland Tippecanoe Tipton Union Vanderburgh Vermillion Vigo Wabash Warren Warrick Washington Wayne Wells White Whitley Contact Information Day Phone Number Select Home Business Evening Phone Number Select Home Business Fax Number Optional: Minority of Asian Descent?   Select Yes No Born in USA?   Select Yes No Ethnicity Select Chinese Taiwanese Korean Japanese Indian Vietnamese Filipino Laotian Cambodian Pacific Islander More Than One Race Other Membership Information Member Type Select Individual Corporate Membership Level (Corporate) Select Copper Bronze Silver Gold Platinum Not for Profit Membership Level (Individual) Select Individual Life Member Associate Student Registration Date Member of other Asian-American Community Organization? Select Yes No Other Asian-American Community Organization Name Membership fee information: For individual: Membership fee waived for individuals. For corporations: Platinum $2000 Gold $1000 Silver $500 Bronze $100 Not-for-profit Organizations* $50 *Please mail a copy of 501(c)(3) letter along with payment. Please make check payable to AAAI and send to: June Kiyomoto Asian American Alliance, Inc. 1000 East 116th Street Carmel, IN 46032 Login Information E-mail Address Password Confirm Password