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ADDRESS INFO
Membership Type *	Imagery International membership ($50.00 for one year) Dues for membership. This is good for one year from the date you signed up. Imagery International membership + ImagiNews hard copy (USA) ($65.00 for one year) Dues for membership ($50), plus a mailed hard copy of the ImagiNews newsletter, which comes out quarterly ($15). Imagery International membership + ImagiNews hard copy (international) ($75.00 for one year) Dues for membership ($50), plus a mailed hard copy of the ImagiNews newsletter, which comes out four times a year ($25).
Payment System *	PayPal secure credit card payment Send a check Mail a check to Imagery International
Your Name * Your First & Last name
Your E-Mail Address * A confirmation email will be sent to you at this address
Choose a Login Name (User ID) * It must be 4 or more characters in length and may only contain small letters, numbers, and the underscore '_'
Enter Verification Text * Please type text from image
List me in the online directory? * Choose whether you want to have your information publicly listed. Only information labeled "This will be displayed in our directory" will be shown.	Yes No
Credentials This will be published in our online directory.
Phone Number Best phone number to reach you. This will not be published.
Website IMPORTANT! Do not forget to put http:// at the front of your web address (example: http://www.example.com)
Business Name The name of your business.
Business Street Address Your business address. This will be published in our online directory.
Business City This will be published in our online directory.
Business State This will be published in our online directory. Please use the two-letter postal abbreviation for the state (for example, CA).
Business Zip Code This will be published in our online directory.
Business Phone Number Your business phone number. This will be published in our online directory. Leave blank if you wish not to have it published.
Business E-mail Your business e-mail. Only one is allowed. It will be published in our online directory. Leave blank if you wish to leave it unpublished.
Occupation
Imagery Training This will be published in our online directory.
Practice Description Describe your practice here.
Country*
State*
City*
Street*
ZIP*