Standard Membership

Name:*

First Name Required Last Name Required

Address Line 1:* Address Line 1 is Required

Address Line 2: Address Line 2 is not valid

City:* City is Required

Country:* Country is Required

State/Province:* State/Province is Required

Zip/Postal Code:* Zip/Postal Code is Required

Email:* Email is Required

Birth date:* Birth date is Required

Ethnicity:* Ethnicity is Required

African-American/African Descent Hispanic/Latino Asian/Pacific Islander Native American Caucasian Other

Gender:* Gender is Required

Male Female

Profession:* Profession is Required

Current Employer: Current Employer is not valid

Salary:* Salary is Required

Under 30 30 - 50k 50 - 70k 70 - 90k 90k +

School Attended?:* School Attended? is Required

Highest Level of Education:* Highest Level of Education is Required

I am interested in these committees:* I am interested in these committees is Required

Membership Committee Community Service Committee Marketing Committee Health Committee Professional Development Committee Entertainment Committee Special Events Committee Civic Engagement & Public Awareness

How did you hear about us?:* How did you hear about us? is Required

Are you unemployed?: Are you unemployed? is not valid

Are you looking to start a business?:* Are you looking to start a business? is Required

Industries of Interest:* Industries of Interest is Required

Business/Finance/Banking Health Real Estate Entertainment Education NonProfit/Government Technology Transportation

Email:* Invalid Email

Password:* Invalid Password

Password Confirmation:* Password Confirmation Doesn't Match

Password Strength Password must be "Medium" or stronger

Paypal

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Pay LAULYP

$60 / Year

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	Standard Membership – Initial Payment $60 / Year	$60.00
	Total	$60.00

Standard Membership – Initial Payment

$60 / Year

$60.00

Total

$60.00