NetIP LA - Membership Form
CHECK ONE
q Renewal ($30-Single $40- Married)
q New Membership ($30-Single $40- Married)
q Personal Information Update
Please indicate which information you would like excluded from future NetIP-LA membership directories by placing an "X" in the box. (Only information with box adjacent will be listed.)
PLEASE PRINT
q First Name: _______________________ MI ____ Last Name: _________________________
q E-mail Address: _________________________________________
Street: ____________________________________________ Apt #: _________
q City: ________________________________________ State: _____ Zipcode: ____________
q Home Phone: (______)__________________ Work Phone: (______)___________________
q Industry: _____________________________ Profession: ____________________________
Employer: ________________________________________________
Date of Birth (M-D-Y): ______-______-_______ Gender: ______
IF MARRIED:
q Spouse's Name: ___________________ MI _____ Last Name: _____________________
E-mail Address: _______________________________________
Date of Birth (M-D-Y): ______-______-_______
Industry: ____________________________ Profession: ____________________________
Employer: _________________________________________________
WHICH COMMITTEES ARE YOU INTERESTED IN LEARNING MORE ABOUT?
q Cultural Events q Professional Development
q Website Development q Marketing & Fundraising
q Public Relations q Print Information
q Community Service
I understand the NetIP Los Angeles (NetIP LA) and any other NetIP North America (NetIP NA) chapter expressly disclaims any responsibility or liability for any damage, loss or injury at, or arising out of, any organized activity. I release all of the aforementioned NetIP-NA chapters of any responsibility.
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________________________________________ Signature |
_____________________ Date |
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________________________________________ Spouse's Signature |
_____________________ Date |
Mail this form and your dues to: NetIP-LA P.O. Box 1230, Artesia, CA 90702
You will receive an email confirmation once your dues and information have been collected.
(A telephone confirmation will be given, if no e-mail address is provided)
(Memberships Expire December 31st 2001)