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Membership First name __________________ MI ____ Last
_____________________________ Date______ Phone (day) _______________________(Eve) ___________________Fax___________________ ____F ____M Birth date _______________ SSN _______________E-mail___________________ Job Title_________________________________________________________________________ Company Name___________________________________________________________________ Company Address ________________________________________________________________ City ______________________________________State ____________Zip __________________ If sponsored by an ABWA member Member name __________________________________ Member #_________________________ Chapter/Express Network Name ______________________ Chapter/Express No.____________ Please check the highest level of education completed ____No H. S. diploma ____H. S. diploma/GED ____ Some College ____ Vo-Tech ____ Business school ____Associate's degree ____Bachelor's
degree ____ Some graduate
____Master's degree ____Doctorate Job title code _____ Industry code ____ Please check appropriate item(s) ___ Business owner ___Retired ___Student Do You plan to join a local chapter ___yes ___no Chapter Name _________________________________________Chapter #___________________ City ______________________________________State ____________Zip __________________ Enclose is my my first-year national dues payment of: ___ $50* Traditional membership __________________ ___ check ___Visa ___ MC ___Discover ___$30 Full-time student __________________ cc#_______________________________________ ___ $50 Company Connection ___________________ Signature __________________________________
*Outside the U.S. add $25 to any Total # _________________ Print and mail to: PLACENTIA STARS |
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Placentia Stars |