New Member Application

GENERAL INFORMATION
First Name:*
Last Name:*
Country:*
Home address:*
City, State, Zip:*
E-mail: * (used for login)
Phone:*
Password for Members Area:*
BUSINESS INFORMATION
Employer:
Country:*
Address:*
City, State, Zip:*
E-mail:
Phone:
Fax:
Please indicate where you would like to receive email from us: work home
BILLING INFORMATION
Method of Payment:*	Check (Make Checks Payable to The International Association of Black Actuaries) Credit Card (American Express, Discover, MasterCard, or Visa)
Amount of Check or Authorized Credit Card Payment:* Membership type:	Please select member type Fellows,Associates, or EA’s, $175 Others with 5+ yr experience, $175 Actuarial Students, $90 College Students, $45 Unemployed Students, $45 Acturies, no longer Practicing, $90 Retirees, $90 Professors, $45 Recruiters or Correspondents, $175 Please select your Actuarial Practitioner or Non-Actuarial Practitioner member type above
Cardholder First Name:*
Cardholder Last Name:*
Card Number:*
Expiration Date: (MMYY):*

EDUCATION & CAREER PROGRESS
What College/University do you currently attend?
What is your classification?	Choose... Freshman Sophomore Junior Senior Graduate Student
Are You Currently Taking Exams?	Choose... Yes No
If so, how many exams have you completed?
How did you hear of the profession?	Choose... Career Fair Teacher/Professor Friend Family Member IABA Member Other

EDUCATION & CAREER PROGRESS
1. What college did you attend for undergraduate studies and what was your major?
List College:
Mathematics Actuarial Science Economics Engineering Other:
2. What college did you attend for graduate studies, if any, and what was your major?
List College:
Mathematics Actuarial Science Economics Engineering Other:
3. Please select the appropriate achieved designations and/or list exams passed
FSA ASA FCAS ACAS EA FIA AIA MAAA
Exams Passed:
Still taking exams:	yes no
4. How many years have you been in the actuarial profession and what is your specialty?
Year Entered Profession:	(Select all that apply below)
Life Health Pension P&C Investments Other
5. What type of organization do you currently work in?
Insurance Consulting Entrepreneurial Other:

IABA PARTICIPATION
1. Would you like to serve as a mentor, mentoree, or both?
Mentor Mentee Both
2. Would you like to serve on one of the IABA committees?
None Finance Membership Mentoring Communications
3. IABA occasionally receives requests for names of our members. Do you want your name released to organizations such as recruiters, colleges and universities or other interested organizations?*
Yes No
Comment on preferences :
4. Do you know of any actuarial professionals or students that we may not have on file? If so please provide their name, email address, phone number, and current employer (school) if possible.
*Cancellation Policy Membership can be renewed on an annual basis and may be paid by credit card. Your credit card account will be automatically charged each year on the day following expiration of your IABA membership. At that time, you will be renewed at the then current membership rate, unless you notify us of your desire to cancel your membership at least fifteen (15) days prior to the renewal date. To cancel your membership, you may send an e-mail request to iabatreasurer@blackactuaries.org. Please be sure to provide your name, address, phone number and e-mail address for authentication, and the reason you want to cancel. Cancellations are processed upon receipt of the cancellation request. Cancellations requesting notification of receipt will receive confirmation via e-mail. All fees and charges are nonrefundable for an annual membership. However, if a user requests cancellation of membership within thirty (30) days following its automatic renewal date, said request will be honored subject to a third-party handling fee (imposed by our credit card processing company) that will be deducted from the amount refunded for each cancellation.

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