School District/Agency ____________________________________________

Mail Address ________________________________________________

________________________________________________

UPS Address _______________________________________

_______________________________________

Current Student Enrollment _______________

Business Administrator or Contact ________________________________________

E-Mail Address ___________________________________

Phone ____________________________________Ext. ________

Fax _____________________________________________

Return completed form to Jeff Kimball, CSIU, P.O. Box 213, Lewisburg, PA, 17837 or fax to (570) 524-5600 or by email to jkimball@csiu.org. A complete membership packet with member agreement will be sent by mail for completion.