Name _____________________________________________________ Title ___________________
       PLEASE PRINT        LAST            FIRST           MIDDLE

Organization Affiliation   _______________________________ Telephone (___)__________
 and Business Address
                           _______________________________ Fax (___)________________

                           _______________________________ Zip Code ________________

Home Address               _______________________________ Telephone (___)__________ 
(Star preferred mailing address) 
                           _______________________________ Zip Code ________________

Electronic Mail Address  ___________________________________________________________

Education                ___________________________________________________________
                                 University                Major             Degree           Date

                         ___________________________________________________________
                                 University                Major             Degree           Date

                         ___________________________________________________________
                                 University                Major             Degree           Date

Training in Organization Development _______________________________________________
(Please be specific regarding program, sponsorship and length.)

                         ___________________________________________________________

Membership in other professional organizations _____________________________________
(Please write full name, including professional licenses.)

                         ___________________________________________________________

I am the author of _________________________________________________________________ 
(You may list two of your publications)    Title                  Publisher                        Date

                   _________________________________________________________________

Languages I speak fluently are: ____________________________________________________

Are you available to work as an O.D. consultant? ____Yes ____No  Usual Fee _________

Membership includes listing your credentials in the International Registry of
Organization Development Professionals, one free copy (which sells for $30), monthly
issue of Organizations and Change, copies of The Organization Development Journal,
plus a $60 discount at each of our conferences (at least two/year). This $110
package provides over $345 in services.

       _____ US$110 Regular member. There are currently no requirements for regular
             members. (Membership includes The Organization Development Journal.)
             I feel that I am a competent O.D. professional, agree to abide by The
             O.D. Code of Ethics and want to use the initials RODP (Registered O.D.
             Professional) after my name.   _____ Yes   _____ No

       _____ US$150 Professional Consultant (additional revenue is for promotional
             material). Please list your O.D. experience in detail. See below for
             details needed. Professional Consultant members who agree to abide by
             The O.D. Code of Ethics may use the initials RODC (Registered O.D.
             Consultant) after their names.

       _____ US$80 full-time Student and not employed full-time.

             I attend full-time at __________________________________________________

       _____ US$80 Senior over 65 (not employed full-time).

       _____ US$100 is enclosed for a one-year subscription starting 1/1/2007 to The
             Organization Development Journal. Over 100 pages/issue, published
             quarterly. It is the most frequently cited O.D. publication in the world.

Membership requirements for becoming a Professional Consultant in The Organizational
Development Institute:

     1) A Doctoral degree in Psychology or an allied field plus the equivalent of
        two years of full-time experience in Organization Development, or

     2) A Master's degree in Psychology, Business Administration or an allied field
        plus the equivalent of four years of full-time experience in Organization
        Development, or

     3) A Bachelor's degree plus the equivalent of six years of full-time experience
        in Organization Development. Two of these six years must have been spent
        working closely with a person who has met the above requirements or in the
        successful completion of a training program in O.D. recognized by us.

     4) In addition to the above, a Professional Consultant must have demonstrated
        competence in Organization Development as evidenced by letters from two
        qualified O.D. consultants stating that they are familiar with your work and
        they consider you fully competent in O.D.

 (Applicants who are not graduates of an OB/OD Program approved by The O.D. Institute will be
 expected to pass a written test on their knowledge and understanding of O.D.)

O.D. Experience ____________________________________________________________________
                       ORGANIZATION             TITLE            DUTIES      HOURS/WEEK    DATES EMPLOYED

                ____________________________________________________________________

                ____________________________________________________________________

Please make checks payable to The O.D. Institute and mail to us at:
11234 Walnut Ridge Road, Chesterland, Ohio 44026-1299, USA.
Our member year ends in August.