Membership and Registration Form: 2016Annual Meeting, April 8-11, 2016, San Francisco, CA

The registration deadline for the 2016 Annual Meeting isMarch 11, 2016.

  • Registration and membership renewal may be completed by submitting this form OR by completing the online registration form via the following link:
  • If you will not be attending the 2016meeting, please renew your membership for the 2016-2017 cycle.

Name / Primary E-mail
Agency/ Organization / Position/Title
Work Address / Home Address
Work Phone / Home Phone
Cell Phone / Alternate E-mail
Yes / Do you give permission to share your agency/organization, position/title, work address, phone number, and primary E-mail address in the ASSM membership roster that is posted on the ASSM website?
No

Place an X in the appropriate box to indicate your membership status.

Membership Level / New / Renew
Regular Membership: Provides supervising and/or consulting services in mathematics as a member of the staff of an education agency of a U.S. state/territory or Canadian province.
Associate Membership: Held continuous Regular Membership for two or more years and no longer meets criteria for Regular Membership.
Emeritus Membership (membership fee waived): Retired from state/provincial agency while a Regular Member of ASSM for a minimum of 5 years.
Yes / No
Will you attend the 2016 Annual Meeting?
If attending, you be staying at the conference hotel (JW Marriott Union Square)?

Place an X next to each function you will be attend.

Fri., Apr. 8: Reception / Sat., Apr. 9: Afternoon Break / Sun., Apr. 10: Lunch
Sat., Apr. 9: Breakfast / Sat., Apr. 9: Dinner / Sun., Apr. 10: Afternoon Break
Sat., Apr. 9: Morning Break / Sun., Apr. 10: Breakfast / Sun., Apr. 10: Dinner
Sat., Apr. 9: Lunch / Sun., Apr. 10: Morning Break / Mon., Apr. 11: Breakfast

Members who register for the Annual Meeting are allowed to bring 1 guest to the Friday evening reception and the Saturday and Sunday dinners.If you will bring a guest please provide your guest’s name and place an X to indicate which meal functions s/he will attend.

Guest’s Name / Friday Reception / Saturday Dinner / Sunday Dinner
Please specify any dietary restrictions

Payment:

Please place an X to indicate the item(s) you will be paying for.

Membership Dues ($50): required for Regular and Associate members.
FULL registration fee for the Annual Meeting ($200)
Discounted registration fee for the Annual Meeting ($150): for those who book their lodging as part of the ASSM room block at the JW Marriott SF Union Square.

Please indicate how payment will be made.

I will submit a personal check.*
My agency/organization will submit a check on my behalf.*
I will make an online payment with my personal credit card.**
My agency/organization will make an online payment on my behalf.**

*Checks should be made payable to ASSM.

** Use the following link to make an online payment:

The registration form (only if you are NOT using the online form) and checks should be submitted to the ASSM Vice-president for Membership:

Dewey Gottlieb

HIDOE/OCISS

475 22nd Ave., Rm. 116
Honolulu, HI 96816

E-mail: