KSCPA - membership application

	user name:
	password:

Members only: To access this area type in your last name in the Username box. Your Password is your membership number, which can be found on any mailing label from KSCPA.. It will follow your name on the label and is preceded by an "M". Enter only the number, do not include the M. (Your membership number is also on your membership card.)

Membership Application

Note: $20 membership application fee

Name
Email
Maiden Name: (if applicable)
Nickname (for name tag use)
Home Address
City
State
9-digit Zip Code
Country
Home Phone
Date of Birth
State Representitive
District#
State Senator
District#
Federal Congressional District#
Prefered Mailing Address	Home Office
Business Name
Address
City
State
Zip
Phone (General Office)
Phone (Direct Line or Ext.#
Fax
General Business Codes
Specific_Bus_Code
Other (Please specify)
Public_Practice
Non_Public
Prefered Position Title if different from general position code above
Interest	Accounting/Auditing Agriculture Business Taxation Business Valuation Computer Technology Construction Industry Consulting Services Controllership Employee Benefits Financial Institutions Goverment/Nonprofits Health Care Industry Human Resources Individual Taxation Litigation Support Personal Fin'l Planning Practice Managment
Original Certification #
State
Date of issue
Reciprocal Certification#'s
State
Date of issue
Do you hold a permit to practice?	Yes No
Chapter
Are you an AICPA member?	Yes No
Are you a previous KSCPA Member?	Yes No
If, yes KSCPA Member #
Admitance Date
Spouse's Name (if applicable)
Name as it appears on your card
Card Number
Card Type
Expiration Date:

Benefits and Services for Members in Industry & Business