APPLICATION FORM

Complete the following information. Please type or print legibly.

Project Title:__________________________________________________________

Principal Author's Name:______________________ HIMAA membership no:_____

Mailing Address:________________________________________________________

City:_______________________________ State:_______ Post Code:_________

Home Phone:________________________ Business Phone: __________________

Mobile Phone:______________________ E-mail Address ___________________

Additional Author(s):_________________________________________________

______________________________________________________________________

______________________________________________________________________

Please read and sign the following statement:

I, ______________________________ (print your full name). I certify 
that the work presented is original and that publication 
of this information does not violate any previous contracts. 
I am empowered to sign for and accept responsibility for 
releasing this material on behalf of all co-authors. 
I hereby waive all claims for royalties in connection with stated 
publication.

Signed: _____________________________________    Date: __________