PHCC National Auxiliary Membership Application
PHCC National Auxiliary Membership Application INFORMATION Senior National Membership (65+)
Regular National Membership Name: Address:
City, State, Zip:
Phone:
Fax:
Company Name:
Email Address: Please select committees that might interest you (select all that apply)
□ Membership □ Legislative
□ Marketing □ By-Laws
□ Education □ Convention Planning
□ Scholarship □ OTHER_____________
PHCC Membership Dues Regular Member:
Full Year ............................ $100.00
Senior Member:
Full Year .............................. $50.00
The PHCC National Auxiliary, in cooperation with the PHCC Association, promotes public awareness of the industry through education and communication. In advance of the action of the Association approving this application for membership, I affirm: 1. 2.
I accept and will comply with the laws and regulations stated in the By-Laws of the Association. I have read and agree to uphold the Auxiliary Ethics and do what I can to fulfill the mission statement.
As in good faith, I hereby affix my signature on this date: _______________________________________________________ Signature of Applicant: ________________________________ Printed Name: ______________________________________
Payment Information To Pay by Check 1. Complete and print this form 2. Write a check payable to PHCC National Auxiliary 3. Send your completed form and check to: Barb Kreifels Membership Secretary, PHCC Auxiliary 4701 Christopher Ct. Lincoln, NE 68516
To Pay by Credit Card 1. Complete this form 2. Send a copy of your application to [email protected] 3. Click the button below or visit paypal.me/PHCCNATLAUXILIARY to pay your dues via PayPal *Paying this way requires making an account with PayPal, which is done for your protection.
Regular National Membership Name: Address:
City, State, Zip:
Phone:
Fax:
Company Name:
Email Address: Please select committees that might interest you (select all that apply)
□ Membership □ Legislative
□ Marketing □ By-Laws
□ Education □ Convention Planning
□ Scholarship □ OTHER_____________
PHCC Membership Dues Regular Member:
Full Year ............................ $100.00
Senior Member:
Full Year .............................. $50.00
The PHCC National Auxiliary, in cooperation with the PHCC Association, promotes public awareness of the industry through education and communication. In advance of the action of the Association approving this application for membership, I affirm: 1. 2.
I accept and will comply with the laws and regulations stated in the By-Laws of the Association. I have read and agree to uphold the Auxiliary Ethics and do what I can to fulfill the mission statement.
As in good faith, I hereby affix my signature on this date: _______________________________________________________ Signature of Applicant: ________________________________ Printed Name: ______________________________________
Payment Information To Pay by Check 1. Complete and print this form 2. Write a check payable to PHCC National Auxiliary 3. Send your completed form and check to: Barb Kreifels Membership Secretary, PHCC Auxiliary 4701 Christopher Ct. Lincoln, NE 68516
To Pay by Credit Card 1. Complete this form 2. Send a copy of your application to [email protected] 3. Click the button below or visit paypal.me/PHCCNATLAUXILIARY to pay your dues via PayPal *Paying this way requires making an account with PayPal, which is done for your protection.
