HTML Membership Application INSTRUCTIONS: Please provide the information requested so that we may accurately register you as a member, publish and distribute a membership directory. You can fill out the form online or print is from here: Download. The completed form, which should be typed or legibly printed, should be returned directly to P.O. Box 1262, Chesapeake, VA 23327 Annual membership dues: $60.00Application DateFull NameFirst Name, Last Name, Middle InitialDate of BirthPlace of BirthCourtesy TitleSpouse NameFirst Name, Last Name, Middle InitialDate of Your AnniversaryHomeCurrent Job TitleOffice PhoneHome Street AddressApartment, suite, etcCityState/ProvinceZIP / Postal CodeOfficeHome PhoneCell PhoneEmail AddressBusiness Street AddressApartment, suite, etcCityState/ProvinceZIP / Postal CodeSpecial Skills or ExpertiseEx. Fundraising; Finance; Business Relations; Planning Events, etc.Professional AffiliationsEducation, Honors, and AwardsSubmit
