M E M B E R S H I P A P P L I C AT I ON ... - IMA Online Store

[Pages:1]PRO MOT IO NA L CO D E

New Application

Renewal

Certification (IMA membership required)

M E M B E R S HI P A P P L I C AT I ON

Revised 2/5/2018

P E R S O N A L IN F O R M AT IO N (pleaseprint)

Mr. Ms. Mrs. Miss Dr.

Last/Family Name/Surname: __________________________________________________________

First/Given Name: _______________________________________________________________________ Middle Initial: ________ Suffix: _______ Date of Birth (m o nth/day/year):_____ / _____ /______ Gender __________________ Please indicate Customer/Member ID: _______________________

PREFERRED ADDRESS

Home Business

Company Name: __________________________________________________________________________________________ Street/P.O.Box: ___________________________________________________________________________________________ City: ___________________________________________ State: ____________________ Zip: ___________________________ Country: ______________________________ Phone:(IncludeCountry/Area/City Codes) _______________________________________ E-mail Address: ____________________________________________________________ Fax: ___________________________ Job Title: ___________________________________________ Area of Responsibility: _________________________________ Number of Employees: _______________________________ Company Revenue: ____________________________________

SIC COD E ? STA ND A RD IND UST RY C L A S S IF IC AT IO N S (please circle one)

Business Services Construction, Mining, Agriculture Education Finance Government Healthcare Insurance Manufacturing Media & Entertainment Nonprofit Pharmaceuticals & Biotechnology Real Estate Student Transportation/Energy Technology/Software Wholesale/Retail/eCommerce Other

A . M E M B E R S H IP IN F O R M AT IO N (All payments must bein U.S.dollars)

Professional Membership . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . $230

Student Membership . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . $39 (You must be ta king 6 or more credit hours per semester a t a college or university.) School ______________________________________ Expected Graduation Date (Year) ________________

Academic Membership . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . $120 (You must be a full-time fa culty member.)

Certification CMA Entrance Fee (Nonrefundable) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . $250 (Except for college students a nd a ca demics.)

Student/Academic CMA Entrance Fee (Nonrefundable) . . . . . . . . . . . . . . . . . . . . . . . $188 (College students a nd a ca demics.)

Chapter Affiliation . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . $0 (Parent) _________________________ (Student) _________________________

Asubscription to StrategicFinance($48,$25 for students) is included in dues and is nondeductible. Members also receive a subscription to Management AccountingQuarterly and the IMAEducational CaseJournal.

B. REG IST RAT ION FEES

Application Processing Fee . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . $15 (A ll new members except Students)

TOTAL DUE (add sections A and B) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . $ _________

A PPLICA NT STAT EMENT

Check here if you have ever been convicted of a felony. Please enclose a confidential letter with a brief explanation of circumstances to the attention of IMA President & CEO.

I affirm that the statements on this application are correct, and I agree to abide by the IMAStatement of Ethical Professional Practice.

Signature: ______________________________________________ Date: ____________

M E T H O D O F PAY M E N T (All pa yments must be in U.S. dolla rs)

Wire Payments All wiretransfers must bemadewith bank fees prepaid.Pleasenotify IMAby e-mail (ima @ima ) tha t you a re pa ying by w ire tra nsfer. Include your na me, a mount sent, a nd w ire tra nsfer receipt number. Check Payments My check for $ _________________ , payable to IMA, is enclosed. (No checks dra w n on foreign ba nks w ill be a ccepted unless they a re pa ya ble through U.S. correspondent ba nks a nd in U.S. dolla rs.) Credit Card Payments Charge my credit card: AMEX Discover MasterCard VISA Card Number: _________________________________________________________________ Security Code: _________________________________ Expires: _______________________ Cardholder Name: _____________________________________________________________ Signature: ____________________________________________________________________ Promotional code (if applicable):_________________________________________________

INST IT UT E OF M A NAGEMENT A CCOUNTA NT S, INC.

10 Paragon Drive,Suite 1,Montvale,NJ07645-1760 ?(800) 638-4427 or (201) 573-9000 ?fax (201) 474-1600 ?ima@ ?

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