|
Please print out this form and provide the following information
to pay your dues and update your listing in the next issue
of the Association Membership Roster.
Then FAX the form to (866) 559-0650
|
| Chapter Affiliation: | _____________________________ |
| Title: | _____________________________ |
| First Name: | _____________________________ |
| Middle Initial: | _____________________________ |
| Last Name: | _____________________________ |
| Class: | _____________________________ |
| Address: | _____________________________ |
| | _____________________________ |
| City: | _____________________________ |
| State: | _____________________________ |
| Zip Code: | _____________________________ |
| Home Phone: | _____ - _____ - _______________ |
Seasonal Address |
| Here From: | __________________(month/day) |
| To: | __________________(month/day) |
| Address: | _____________________________ |
| | _____________________________ |
| City: | _____________________________ |
| State: | _____________________________ |
| Zip Code: | _____________________________ |
| Phone: | _____ - _____ - _______________ |
Business Info |
| Firm Name: | _____________________________ |
| Position: | _____________________________ |
| Firm Address: | _____________________________ |
| | _____________________________ |
| City: | _____________________________ |
| State: | _____________________________ |
| Zip Code: | _____________________________ |
| Business Phone: | _____ - _____ - _______________ |
| Business Fax: | _____ - _____ - _______________ |
| Email Address: | _____________________________ |
| Receive Chapter notices by e-mail? | Yes - No (circle one) |
Firm Type (circle one)
Maritime ashore
Sailing
Engineering ashore |
Professional: MD, CPA, JD, etc.
Military Service
Corporate |
|
| Payment Info |
| 2006 Dues: | $50 |
| 2007 Dues: | $____________________________ |
| Scholarship Fund: | $____________________________ |
| College Fund: | $____________________________ |
| Annual Fund: | $____________________________ |
| FSMAA Development Fund: | $____________________________ |
| Total: | $____________________________ |
| Type of Credit Card: | Visa - Mastercard - AMEX - Discover (circle one) |
| Credit Card #: | _____________________________ |
| Expiration: | _____________________________ |
