Company Name:

*

Street Address 1:

*

Street Address 2:

City:

*

State:

Select State: Alaska Arizona Arkansas California Colorado Connecticut Delaware Florida Georgia Hawaii Idaho Indiana Illinois Iowa Kansas Kentucky Louisiana Maine Maryland Massachusetts Michigan Minnesota Mississippi Missouri Montana Nebraska Nevada New Hampshire New Jersey New Mexico New York North Carolina North Dakota Ohio Oklahoma Oregon Pennsylvania Rhode Island South Carolina South Dakota Tennessee Texas Utah Vermont Virginia Washington Washington DC West Virginia Wisconsin Wyoming *

Zip:
^{Example: 45377}

*

Phone:
^{Example: 937-555-6789}

Fax:
^{Example: 937-555-6789}

Website:
^{Example: www.website.com}

Email:
^{Example: username@website.com}

Contact Person:

Additional Contact Person:

If your company sells a product, what is it?

If your company provides a service, what is it?

Do you want a free tabletop at an upcoming meeting?

YesNo

Do you want to advertise in the Update Newsletter?

YesNo

Do you want to advertise in the Membership directory?

YesNo

Do you plan on having a booth in the next trade show?

YesNo

Do we have your consent to fax you information about events and programs?

YesNo

Sponsored by:

Dues are $360.00 per year, plus a $25.00 initiation fee for a total of $385.00

Application Total:

Payment Method:

CheckCredit Card

Credit Card Number:

Security Code:

Expiration:
^{Example: 05/2012}