Arkansas Association of Instructional Media Membership Information Form
Membership runs Conference to Conference

If you attended conference, your membership dues and information was collected at registration. You do not need to submit this form.

If you were unable to attend conference and simply want to renew your membership fill out this form.

If you are a new member, please use this form.
Email address *
I will pay my membership dues by *
Step 1: Personal Information
First Name *
Your answer
Last Name *
Your answer
Home Address *
Street, Apt, Number, etc.
Your answer
City *
Home Address City
Your answer
State *
Home State
Your answer
Zipcode
Home Zipcode
Your answer
Personal Phone Number *
Your answer
Company or School Name *
If you are a public school teacher, please include the district. Ex: Westside Elementary, Greenbrier) IF YOU ARE RETIRED, please put the word "RETIRED" in each of the blanks for this area.
Your answer
Company or School Address
Street, Apt., Number, etc. IF YOU ARE RETIRED, please put the word "RETIRED" in each of the blanks for this area.
Your answer
City *
IF YOU ARE RETIRED, please put the word "RETIRED" in each of the blanks for this area.
Your answer
State *
IF YOU ARE RETIRED, please put the word "RETIRED" in each of the blanks for this area.
Your answer
Zipcode *
IF YOU ARE RETIRED, please put the word "RETIRED" in each of the blanks for this area.
Your answer
Company or School Phone *
IF YOU ARE RETIRED, please put the word "RETIRED" in each of the blanks for this area.
Your answer
Preferred Email address for the listserve *
Your answer
Alternate Email Address (optional)
Your answer
I prefer to receive mailings from AAIM at my
Step 2: Membership Registration
I am registering for: *
If paying by Credit Card, please complete your membership by following the link below to AAIM Card Payment Page. https://gateway.clearent.net/paylink/000001380682/10019874
Your answer
If paying by check, mail your payment to: Devona Pendergrass, 149 Brushy Knob Trail, Mountain Home, AR 72653
Your answer
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