International Community Service
Membership Application Form
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Membership, if approved, is renewable annually
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Last Name:
First Name & MI:
Address:
City:
State & Zip:
Social Security No.:
Date of Birth (mm/dd/yy):
Sex (Male or Female):
Phone (include area code):
Fax (include area code):
Email:

//Please specify 
"New Application" or "Renewal":
Current Status (Student, Scholar, Other):
Type of Visa (F-1, J-1, H-1, PR, etc.):
College or University Attending:
Country of Origin:

//Educational
Highest Degree Awarded:
Date (month/year):
Major:
School Attended:

//Professional
Affiliation / Employer:
Position / Title:
Field of Specialization:
Reference (name, phone, email):

I certify that the above information is true 
and complete to my best of knowledge -

Applicant's Signature:
Date (mm/dd/yy):

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Please return completed application form to:

International Community Service
P. O. Box 141742
Gainesville, FL 32614-1742 (USA)

Email: info@icsweb.org  [or]  i4cs@aol.com
Phone: (352) 331-0087
Fax:   (352) 331-0908