RPCN Membership Application Form

		RPCN Member Application Form Home \| Member Information

Instructions: Please fill in the information as indicated in the boxes below. Then PRINT this form and mail it with a check made out to "RPCN" to RPCN, P.O. Box 18086, Rochester, NY 14618-0086.

The bold print below indicates required information. Regular print indicates optional information. As a member, your name and address will be automatically entered on our "Membership" web page, unless you specify not to put it there. You will also receive membership materials, which will include instructions on how to be listed in our "Expertise" web page, which does not happen automatically. Your membership will begin when your dues are received.

Please enroll me as:

	Mr. Ms. Dr.
Name:
Nickname:
Company Name:
Nature of Business:
	(In 4 or 5 words, please state what your business does.)
Mailing Address 1:
Mailing Address 2:
City/Town: State: Postal Code: Country:
Home Phone: (xxx) xxx-xxxx
Work Phone: (xxx) xxx-xxxx	Ext.
Fax Phone: (xxx) xxx-xxxx	Call First
E-Mail Address:
Web Site (URL):
Add my email address to the RPCN Broadcast Email List: Add my email address to the RPCN Discussion Email List: NOTE: By agreeing to have your email address added to the RPCN Discussion Email List you agree to adhere to that list's policy and procedures.
How did you first hear about RPCN?

Please PRINT this form and mail it with a check made out to "RPCN" to RPCN, P.O. Box 18086, Rochester, NY 14618-0086.