IEEE PHOENIX AREA CONSULTANTS NETWORK MEMBERSHIP APPLICATION FORM

____ Full Member

____ Associate Member*

Name (First, MI, Last):

_______________________________________________________

IEEE member ____ yes  ____ no

If yes, IEEE number ____________________

IEEE membership is not required (there is a small surcharge for non-IEEE members)

Area(s) of technical expertise:

_______________________________________________________

Home address:

 _______________________________________________________

_______________________________________________________

Home telephone number:

_______________________________________________________

Home fax number:

_______________________________________________________

e-mail address:

_______________________________________________________

Web site URL:

_______________________________________________________

Company name:

_______________________________________________________

Title :

_______________________________________________________

Company address:

_______________________________________________________

_______________________________________________________

_______________________________________________________

Work telephone number:

_______________________________________________________

Work fax number:

_______________________________________________________

Preferred contact:  ______ home     ______ work

Signature:  ____________________________________________     

Date:  ______________

Mail completed application with membership fee to:

C. Bruce Johnson, Vice President, PACN Executive Board, P. O. Box 51551, Phoenix AZ  85076-1551

Full membership fees: (We've reduced our prices!)

IEEE member                            $25/yr

Non-IEEE member                    $30/yr 

Associate membership fee          $20/yr

 *Associate membership is available to those who are not directly involved in consulting and engineering.  Associate members do not have voting privileges and are not listed in the PACN directory or on the PACN web site.  Associate members can attend all meetings and take part in all activities.