ADVISORY COUNCIL MEMBERSHIP APPLICATION
July 1, 2009 - June 30, 2010
Please provide the following information and return with
your check, credit card number, or purchase order by December 31, 2009 to the address listed
below. Thank you!
NAME/MAILING ADDRESS:
_________________________________________________________________________________________________________________________
_________________________________________________________________________________________________________________________
_________________________________________________________________________________________________________________________
PHONE_______________________________ FAX____________________ EMAIL__________________________
ADD AFFLIATION NAME AND ADDRESS IF JOINING AS AN INSTITUTIONAL REPRESENTATIVE:
_________________________________________________________________________________________________________________________
_________________________________________________________________________________________________________________________
PREVIOUS CONTACT PERSON OR REPRESENTATIVE (if applicable): ._________________________________________
MEMBERSHIP CATEGTORY (CIRCLE ONE):
Individual membership $100.00*
Institutional membership $200.00*
METHOD OF PAYMENT
___check (payable to “Northeast Conference”)
___Purchase order # _____________________
___Visa/MC # |__|__|__|__|-|__|__|__|__|-|__|__|__|__|-|__|__|__|__|
Exp. date |__|__|__|__|__|__|
Print name as it appears on card______________________________________________________________________
Signature_________________________________________________________ Date___________________________
Return to:
NORTHEAST CONFERENCE ADVISORY COUNCIL
AT DICKINSON COLLEGE
PO BOX 1773
Carlisle, PA 17013
*Please note: Neither membership includes the conference registration fee.