OREGON ASSOCIATION OF ADMINISTRATIVE LAW JUDGES

                                                         P.O. BOX 3626

                                                Salem, OR 97302-0626

                                                 email:  membership@oaalj.org

                                                      Membership Form

Name:             ____________________________________________________

                                                                    (please print)

Mailing

Address:         _____________________________________________________

                        street                                      city                  state                            zip

Work phone:  _____________________   Home phone:   ___________________

The board plans to offer our newsletter electronically.  Please provide your

preferred e-mail address for this purpose.

e-mail (work)  ___________________    e-mail (home)  ___________________

Employing

Agency or Employer: __________________   Full Time:  ____  Part Time:  _____  

Business Address:  _________________________________________________

                                    street                          city                     state                           zip

Are you willing to serve on the board or a committee?  _____________________

Issues that concern you:  _____________________________________________

__________________________________________________________________

Please make your check payable to the Oregon Association of Administrative Law

Judges in the amount of $65.00 and send it to PO Box 3626, Salem OR 97302.

We appreciate your support.

Signature:  ____________________________         Date:  ___________________