National WIC Association Individual Membership Application
National WIC Association
Individual Membership Application
New Member
Renewing Member
Name _____________________________________________________ Title ________________________________________ Credentials___________ Mailing Address ____________________________________________________ City _______________________ State __________ Zip Code ______________ Contact Phone ________________________ Fax ________________________ Contact Email _______________________ National WIC Association Membership Runs from January 1 through December 31. Please choose from the dues options below: Individual Member/$50 Individuals employed or formerly employed by State or Local WIC agencies OR individuals responding to the nutrition needs of at-risk women and children. Membership is personal, not agency or organization-based. Student Member/$25 For students who are enrolled in an accredited undergraduate or graduate program. Students must provide a photocopy of a current student ID by email, fax, or mail. Retired Member/$10 For individuals who have retired and are no longer involved in any career activity. Please Select Payment Method: Purchase Order #: ___________________________ Check # (Payable to NWA Tax ID: 521482678): ________________ Visa MasterCard American Express Discover Credit Card #: __________________________ CVC: _________ Exp.: ________ Name on Card: ______________________ Signature: _____________________ Billing Address: ____________________________________________________ Bill me: Email invoice to: _______________________________
Please send application and payment to: National WIC Association 2001 S St NW Ste 580 Washington, DC 20009 Fax: 202-387-5281 Email: [email protected]
Individual Membership Application
New Member
Renewing Member
Name _____________________________________________________ Title ________________________________________ Credentials___________ Mailing Address ____________________________________________________ City _______________________ State __________ Zip Code ______________ Contact Phone ________________________ Fax ________________________ Contact Email _______________________ National WIC Association Membership Runs from January 1 through December 31. Please choose from the dues options below: Individual Member/$50 Individuals employed or formerly employed by State or Local WIC agencies OR individuals responding to the nutrition needs of at-risk women and children. Membership is personal, not agency or organization-based. Student Member/$25 For students who are enrolled in an accredited undergraduate or graduate program. Students must provide a photocopy of a current student ID by email, fax, or mail. Retired Member/$10 For individuals who have retired and are no longer involved in any career activity. Please Select Payment Method: Purchase Order #: ___________________________ Check # (Payable to NWA Tax ID: 521482678): ________________ Visa MasterCard American Express Discover Credit Card #: __________________________ CVC: _________ Exp.: ________ Name on Card: ______________________ Signature: _____________________ Billing Address: ____________________________________________________ Bill me: Email invoice to: _______________________________
Please send application and payment to: National WIC Association 2001 S St NW Ste 580 Washington, DC 20009 Fax: 202-387-5281 Email: [email protected]
