Academy of Television Arts & Science
Peer Group Change Form
PLEASE NOTE: The fee for National Active membership is $150.00 per year, Associate membership is
$75.00. If you upgrade from Associate status to National Active, please include payment for the
additional $75.00. Payment must be received with this form.
MAILING ADDRESS IF CHANGED
I DO NOT WISH TO RECEIVE CORRESPONDENCE VIA EMAIL
CURRENT PEER GROUP
PREFERRED PEER GROUP
Please provide your credits qualifying you for new Peer Group or status. Attach additional credits
and/or resume. This form can be faxed to 818/754-2808.
TITLE / POSITION
# OF ON-AIR
& PHONE NUMBER
Governor Signature of Approval