Date First name* Last name* Title / Occupation* Company / Affiliation* Address* Street address Street address 2 City State ZIP Code Country Cell phone Work phone* Email* Email address will be used for club announcements and electronic newsletters. Sponsored by* Type of Membership[fields_group fields_group-171]RegularSustainingNon-Resident/Virtual[/fields_group] Dues Billing Preference[fields_group RegularDues]Semi Annually / $180 (+$100 initiation fee)Annually / $360 (+$100 initiation fee) [/fields_group] [fields_group SustainingDues]Semi Annually / $280 (+$100 initiation fee)Annually / $560 (+$100 initiation fee) [/fields_group] [fields_group NonDues]Annually / $200 (no initaiton fee)[/fields_group][fields_group NoDues]Choose membership type above[/fields_group] Please leave this field empty.
