MAINE INDOOR AIR QUALITY COUNCIL 

Membership Application Maine Indoor Air Quality Council Registration Form The Council invites individuals to become official members by completing this registration form and paying annual dues of $50.00. Benefits of membership include regular communication of policy, education, and general items of IAQ interest; peer review of Council documents; a complimentary subscription to Indoor Environment Connections (a $72.00 value); committee memberships, and voting privileges.  If you apply for membership via this web page please remember to mail your check or money order (made payable to "Maine Indoor Air Quality Council") to P.O. Box 2438, Augusta, ME 04338-2438. Alternatively, you can print this form out by clicking the print button on your browser, complete the form by hand and mail with your check included.  The MIAQC dues year runs from July 1 through June 30.  If you do not wish to be a dues-paying member, you may submit this form for inclusion on the Council's mailing list for educational offerings. Note:  Our on-line membership application form is currently not functioning.  Please print our PDF version of the Membership Application, and either fax it or scan/e-mail it to info@maineindoorair.org.  A PDF Dues Payment Form is also available.  We apologize for any inconvenience.

Name Mr. Ms. Dr. Occupation _ Academic Administrator Architect Code Enforcement Official Custodian Engineer Equipment/Products Supplier Facility Manager General Contractor Government Employee Hazardous Materials Contractor Health Care Provider HVAC Contractor HVAC Technician IAQ Specialist/Consultant Industrial Hygienist Insurance Company Employee Laboratory Technician Lawyer Lessor Occupational Health & Safety Officer Other Plant Operator/Engineer Physician (General/Specialist) Physician (Occupational Health Specialist) Public Health Organization/Agency Employee Testing Company Employee Company/Employer Address City,State,ZipCode , Office-Phone(###) ###-###,Extension Fax (###)###-#### Home-Phone (###)###-#### E-mail Address (required for voting members) Primary Expertise Medical/Health Professional/Technical Public Policy/Government Operations/Maintenance Secondary Interests None Medical/Health Professional/Technical Public Policy/Government Operations/Maintenance While holding down Ctrl key,select all that apply   Membership Type Mailing List (free) Dues-Paying Member ($50.00/yr.)   If becoming a dues-paying member, would you consider joining committee(s) at this time?  If so, please select a maximum of 2 choices Committee(s) None Education Communications/Public Relations Membership Public Policy Best Practices Nominating   While holding down CTRL key, select all that apply