======================================================================== AUSTRALASIAN SPEECH SCIENCE AND TECHNOLOGY ASSOCIATION INCORPORATED ----------------- A.S.S.T.A. Inc. ----------------- MEMBERSHIP APPLICATION FORM Surname................. Given Names.................... Title........ Full Postal Address...................................................... ......................................................................... ......................................................................... Work Phone [ ]( ).............. Message Phone [ ]( ).............. Home Phone [ ]( ).............. Fax [ ]( ).............. Electronic Mail.......................................................... Work Affiliation......................................................... Work Position held....................................................... Relevant qualifications held Qualification Institiution Date obtained Grade of membership applied for : Ordinary / Associate / Student / If "Ordinary"... Ordinary Membership requires that the applicant be actively involved in research or development in the area of speech science and technology. In 20-50 words, please state the nature of your involvement in speech science and/or technology. If "Student"... Student Membership requires that the applicant be enrolled full-time in a course of study that is related to the area of speech science and technology. In 20-50 words, please describe your course of study, its relation to speech science and/or technology, and the name of your course supervisor. Supervisor's Name: Are you enrolled full-time? ***************************************************************************** *PLEASE RETURN YOUR COMPLETED FORM TO THE ASSTA SECRETARY BY POST OR E-MAIL * ***************************************************************************** ASSTA Inc, GPO Box 143, Canberra City, ACT, 2601 secretary@assta.org