Spouse's Name:_________________________________________________________

Mailing Address:_________________________________________________________

Home Phone:(_____)______________ Business Phone:(_____)___________________

E-mail:_________________________ FAX:(_____)_____________________________

Employer Name:_________________ Profession:______________________________

Choose the area you are interested in volunteering for:
 

Newsletter	[ ]	Social/Cultural Events	[ ]	Community Service	[ ]
Membership	[ ]	Corporate Relations	[ ]	Public Relations	[ ]

Interests________________________________________________________________

Would you like your name included in the membership directory?     YES [   ]  NO [   ]
 

Type of member:

Single($10.00)

[  ]

Couple ($15.00)

[  ]

Siignature_______________________________________Date______________________

Mail the completed membership form with check to:
NetIP-Kansas City
12490 Quivira # 3422, Overland Park, KS 66213