<p> Virginia Interscholastic Athletic Administrators Association 2016-17 MEMBERSHIP APPLICATION</p><p>Mail Application & Payment To: Ryan Molloy, c/o Atlee High School…9414 Atlee Station Road, Mechanicsville, VA 23116…Email: [email protected]</p><p>Make Checks/Money Orders Payable To: VIAAA</p><p>First: ______M.I.______Last: ______DISTRICT: ______</p><p>Suffix: ______Informal First: ______Title (CAA/Etc.): ______REGION:______Year Certified:______School: ______Class: 6A, 5A, 4A, 3A, 2A, 1A INDP. M/S Retired School or Home Member NIAAA: Yes No Address: ______</p><p>City, State: ______, ______Zip: ______</p><p>Phone: (____) ______-______FAX: (____) ______-______E-MAIL______</p><p>Position: ______</p><p>MEMBERSHIP OPTIONS: ACTIVE MEMBER $115.00 ______(Dual VIAAA & NIAAA) RETIRED MEMBER $20.00 ______(VIAAA only) LIFETIME MEMBER $250.00______(VIAAA only) LIFETIME MEMBER VIAAA joining NIAAA $80.00______LIFETIME MEMBER NIAAA joining VIAAA $35.00______</p><p>NIAAA Membership Information ONLY Membership Office Use Only  New Membership Renewal Membership # ______Check/Money Order # ______Check/Money Order Date ______ Male  Female Social Security # ______- ______- ______ School  Personal  Money Order  Cash  Smoker  Non-Smoker Date of Birth ______</p><p>The NIAAA has formed an ad hoc committee to study diversity among our members. In this regard, a database has been instituted to collect this information from our membership applications. We appreciate your completion of this section so we may better serve our members. Please check one:</p><p> Caucasian  African American  Asian  Pacific Islander  Latino  American Indian  Multi-Cultural  Alaskan Native</p><p>If none of the above codes seem appropriate, please indicate your background ______.</p><p>All Lifetime members must complete a Membership Application each year to verify your information.</p><p>Updated 4/27/16 </p>