WOMEN’S INFORMATION NETWORK OF SIMI VALLEY
Membership Application
Date
INSTRUCTIONS:
New Members complete through Line 12
Renewing Members complete through Line 3 & Line 12
Members requesting page/badge change complete through Line 12
See WINS fee schedule (included in package) at bottom of page
Referred by:
1. Type of Membership:
New Member Individual - $78.00
New Member Corporate - $100.00
Corporate Renewal - $90.00
Member Individual Renewal - $50.00
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. Description of Business and/or Services for Directory Page (Describe in 50 words or less):
10. Organizational Affiliations/Memberships Held for Directory Page
11. Company Membership only: If you are ordering additional directory page(s), badge(s), of directory(ies) email a
separate page for each. Be sure to include appropriate fees.
12. To order badge please complete:
Name:
1 line
Business Name/Organization:
2 line
13. Would you like a hyperlink from our site to yours? ( $25 )
Yes
No
14. Hyperlink: