| Name | |
| Address | |
| City | |
| State | Zip |
| Phone (H) | |
Phone (W) |
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| School | |
| District | |
| Are you a member of International Reading Association? Yes No | |
| Membership # | |
| Expires | |
| Local and State Dues: (select one) Professional $30 New Renewal Student $15 New Renewal Retired $15 New Renewal |
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