WOMEN'S INFORMATION NETWORK OF SIMI VALLEY
Membership Application
Date
INSTRUCTIONS:
New Members complete through Line 11
Renewing Members complete through Line 3 & Line 11
Members requesting page/badge change complete through Line 9
See WINS fee schedule at bottom of page
Referred by:
1. Type of Membership:
New Member Individual (Jan-Dec) - $80.00
New Member Individual Prorated (July-Dec) - $40.00
New Member Corporate (Jan-Dec) - $120.00
New Member Corporate Prorated (July-Dec) - $60.00
Renewal Individual Member - $50.00
Renewal Corporate Member - $90.00
2. First Name
Middle Name
Last Name
3. Title/Position:
Business/Organization:
4. Business Address:
City:
Zip:
5. Business Phone: (
)
Mobile#: (
)
6. E-mail:
URL:
7. Home Address:
City:
Zip:
8. Home Phone: (
)
Preferred Mailing Address: Business
Home
9. Information for Name Badge:
Name:
1 line
Business Name/Organization:
2 line
10. Would you like a hyperlink from our site to yours? ( $25 )
Yes
No
11. Hyperlink: