Name:
Company/Organization:
Title: email:
Address:
Telephone #: Fax #:
Do you own your business? q Yes qNo
Committee Interest: (please
check all that apply)
qDues qFinance qWeb
Site qMembership
qFundraiser/Special
Events qSpeaker’s Bureau
qEducation/Training qNewsletter qOther:
Membership Fees:
Individual:
qAnnual
Membership - $ 50.00
qStudents - $ 25.00
Corporate:
q1 – 5 employees - $ 250.00
q6 – 15 employees - $ 500.00
q16 – 50 employees - $ 750.00
qover 50 employees - $ 1,000.00
Demographics: (for statistical profile only)
Age q under 25 q 25-34 q 35-44 q 45-54 q 55-over
Sex q Male q Female