Individual Membership Application

* required fields

Prefix: Mr. Mrs. Ms. Dr. Prof. Other
* First Name:
Middle Name:
* Last Name:
Suffix:
Business Title:


 YES! I would like to join T&DI and ASCE
 I am currently a member of ASCE and wish to select T&DI as my primary Institute at no additional cost. ASCE Member ID (must provide if currently an ASCE member)
 I am currently a member of ASCE and SEI/G-I/AEI/EWRI/COPRI/CI and wish to join T&DI for an additional $20.
 I would like to join T&DI only.


Personal Information

Complete this section if you are not already an ASCE member or if you want to correct ASCE Membership data.

Residence
Address:
 
City:
State:
Other:
Zip Code:
Country:
Phone:
Business
Name of Employer:
Address:
 
City:
State:
Other:
Zip Code:
Country:
Phone:
Fax:
E-mail:
Date of Birth: (mm/dd/yy)
Preferred mailing address: Residence Business


Business/Position Category

Consulting
02 Consulting Engineering Firm, Engineer in Private Practice
Contractor
31 Contractor
Government
51 Federal
52 Regional Authority
53 State
54 Municipal, County, Township & District
55 Foreign
Industry/Utility
06 Commercial and/or Industrial Organizations (including transportation and privately owned utility companies)
07 Producer of Construction Materials
08 Manufacturer of Equipment and Supplies
Education
15 Educator, Professor, Instructor
Special Interest Organization
16 Special Interest Organization, Association
Other
18 Other


Education Information

Please use appropriate abbreviations when possible. Please list all degrees received or being pursued, using appropriate abbreviations (i.e., BSCE, MSCE, Ph.D., MBA, MSEM)

College/University Dates Attended Degree/Major Graduation Date


Professional/Work Experience

You may paste a recent resume in lieu of completing this section.



Employer Length of Employment Position
Years Months
Years Months
Years Months


How many years have you been active in the transportation and/or development industry?

Please provide a statement describing your activity in the transportation and/or development industry.



Professional Licenses and Associations

Please list professional licenses and professional association affiliations:




Payment Information and Signature

Membership
Category		 Qualifications Total Due
ASCE and T&DI Joint Membership (Dues vary according to membership grade) Membership materials for ASCE will be forwarded to you. $
T&DI Membership as an Additional Institute ($20) For current members of ASCE and SEI, G-I, EWRI, COPRI, CI, or AEI - Institutes of ASCE. $
T&DI-Only Membership ($145) For individuals interested in transportation and development. $


*Annual dues do not need to be included with your application. You will be invoiced for dues once your application has been processed. You may submit your application either by pressing the Submit button at the bottom of this form or by faxing it to 703-295-6421, or by mailing it to ASCE - T&DI Membership, 1801 Alexander Bell Drive, Reston, VA 20191-4400 USA

I authorize the Institute to verify the information contained in this application and, to that end, to contact any educational institution, professional society, publisher, employer, or other entity named or identified in this application or in any document submitted in support of this application. I hereby consent to and authorize the release and disclosure to the Transportation & Development Institute of any information, records or correspondence as required to verify the information in the application, which is held by any such entity identified in this application.

Date: