Membership Reinstatement Request Form

PSIA-AASI Western Region - Membership Reinstatement Request

For members who have let their annual dues and education lapse, we offer the option of reinstating your former membership. We recommend you reinstate with the division you currently work or live in. The PSIA-AASI Western Division covers the territory of CALIFORNIA and NEVADA.

Name*
First Middle Last
Nickname
Former Last Name (if used with former membership)
Current Email*
Former Email(s) (if used with former membership)
Current Home Phone
Current Cell Phone
Date of Birth*
Month
Day
Year
Gender*
- Male
- Female
Current Mailing Address*
Please list the address where you would like your membership card and/or certifications mailed.

Street Address Address Line 2 City State ZIP Code
What years was your previous membership active?*
Former Region*
Former Level of Certifications, Discipline, and Year Obtained*
Former Address or other information that would help us match your old membership record:
Do you wish to reinstate your membership as Alumni?*
Individuals wishing to re-join PSIA-AASI as an Alumni member must have an original join date of at least 10-years prior. Alumni members will be excused from continuing education requirements and their certifications will be inactive. View our page on Alumni Membership for the full details: https://psia-w.org/membership/alumni/
- Yes
- No
- I'm not sure
MEMBERSHIP REINSTATEMENT REQUIREMENTS
Membership runs from July 1 to June 30 of each year.

Less than 2 years lapsed:
Pay last season’s missed dues & this season’s current dues
Become current on your education credit requirements (1-day/6-CEUs each season OR 2-days/12-CEUs every 2-seasons)

More than 2 years and less than 5 years lapsed:
Pay $210 for reinstatement & this season’s current dues.
Attend 1-day of education (6-CEUs) for each season of unpaid dues.

More than 5 years lapsed:
Pay $380 for reinstatement & this season’s current dues.
Attend 4-days of education (24-CEUs) within two seasons.
Signature
Signature*
After submitting this form it will be reviewed by the Western Region. You will be contacted with the next steps and/or emailed an invoice to complete your membership reinstatement. FEES WILL NOT BE REFUNDED. QUESTIONS? Email: info@psia-w.org Call: 530-587-7642*
- By checking this box I confirm that I am reinstating a former PSIA-AASI membership and wish to do so with the Western division. I understand that fees are not refundable.
After submitting this form it will be reviewed by the Western Region. You will be contacted with the next steps and/or emailed an invoice to complete your membership reinstatement.
FEES WILL NOT BE REFUNDED.
QUESTIONS?
Email: info@psia-w.org
Call: 530-587-7642

PSIA-AASI Western Region - Membership Reinstatement Request

For members who have let their annual dues and education lapse, we offer the option of reinstating your former membership. We recommend you reinstate with the division you currently work or live in. The PSIA-AASI Western Division covers the territory of CALIFORNIA and NEVADA.

MEMBERSHIP REINSTATEMENT REQUIREMENTS

Signature

After submitting this form it will be reviewed by the Western Region. You will be contacted with the next steps and/or emailed an invoice to complete your membership reinstatement. FEES WILL NOT BE REFUNDED. QUESTIONS? Email: info@psia-w.org Call: 530-587-7642

CONTACT US

After submitting this form it will be reviewed by the Western Region. You will be contacted with the next steps and/or emailed an invoice to complete your membership reinstatement.
FEES WILL NOT BE REFUNDED.
QUESTIONS?
Email: info@psia-w.org
Call: 530-587-7642