Membership Enrollment Form


Date _________________________________________

Organization Name ____________________________

Address ______________________________________

City _________________________________________

State/Zip Code _______________________________

Phone ________________________________________


(Please Print)
Authorized by ________________________________

Title ________________________________________

Email ________________________________________


I would like to enroll the following employees:
(If you need to enroll more than 5 people, add them on a seperate sheet.)
	  Name			   Title		         Email

1. ______________________   ______________________  ______________________

2. ______________________   ______________________  ______________________

3. ______________________   ______________________  ______________________

4. ______________________   ______________________  ______________________

5. ______________________   ______________________  ______________________

Enclosed is a check for $__________________
(Membership fee is $100 per person)

______ Enclosed is a copy of our tax exempt 501 (c) 3 letter. (Required)


Send all documents to:

ITAV, Inc.
Attn: Membership Dept.
PO Box 712
Teaneck, NJ 07666

                        Thank you for becoming a member!