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International Association of Scientologists
2012 Member

Your Info (Fields marked with "*" are required)

If your address has changed from the address the census was mailed to, please enter your new address info below:

* First Name
* Last Name
Address (optional)
Address Line 2
State or Province
Zip or Postal Code
Home Phone
Mobile Phone
Office Phone
* Your E-mail
(Keep up-to-date with the latest news on IAS-sponsored campaigns)
Language Spoken

Your Views

1. What do you consider are the most important benefits you receive as an IAS member?
2. What made you decide to become an IAS member (or advance your Honor Status) when you did?
3. What kind of acknowledgement or award would you like to receive from the IAS for upgrading your membership or Honor Status?
4. What kind of news and updates are you interested in receiving from the IAS throughout the year?
5. Do you receive Impact Magazine? Yes No
     If YES, do you read it? Yes No

Is there any topic or subject you would like to see covered in Impact Magazine?
6. Do you receive the e-mail updates from the IAS? Yes No
     Do you read them? Yes No
7. Who do you know who could be eligible for an IAS Freedom Medal?
8. Is there anything about the International Association of Scientologists that you would like more information about or any questions you would like to ask?

Service to You

1. Which IAS Membership or Honor Status do you have?
Free Six Month Membership Annual Membership Lifetime Membership
Sponsor Senior Honor Roll Patron Meritorious
Crusader Patron Silver Meritorious or Above
Honor Roll Patron with Honors
2. Is there anyone in your family who does not currently have an IAS membership?
3. Do you have your IAS membership card? Yes No
4. Do you receive duplicative mailings from the IAS? Yes No

(if YES, give specifics so this can be corrected)
5. If you have an Honor Status in the IAS:
  1. Did you receive your pin? Yes No

  2. Did you receive your plaque (or trophy)? Yes No

  3. Have you been awarded with your status at
    an IAS dinner or Patrons Ball? Yes No
6. Birth Date?
7. Occupation?
8. Case Level?
9. Training Level?
10. Your Org or Mission?
11. Are you currently taking services? Yes No
If yes, which service?

IAS Field Disseminator Program

If you are an IAS Field Disseminator

1. Is there anything you would like assistance with or more information on?
2. What kind of Field Disseminator Awards do you like to receive? (jackets, pens, portfolios, etc.)
3. Are there any Field Disseminator Awards or commissions you have earned but not received?

If you are not an IAS Field Disseminator:

4. Would you like to receive information about the IAS Field Disseminator program and how you can earn commissions for assisting others to become members and for raising funds for the IAS?
Yes No

Your Plans for the Future

1. What would you like to accomplish in the next year?
2. What plans do you have for advancing your IAS status in the next year?
3. Are you qualified for the Sea Org?
Yes No
4. If you are qualified, have you considered joining the Sea Org at IASA or made plans to do so?
Yes No

Thank You!

Thank you very much for filling out the IAS 2012 census!

Please let us know if there is anything else you would like to communicate to the IAS or any assistance you need as a member.

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