AFFILIATE APPLICATION

RALEIGH CHAPTER                    Date ________________

COMPANY _________________________________________________________

OFFICE PHONE _____________________________________________________

CONTACT PERSON __________________________________________________

CONTACT PERSON PHONE ___________________________________________

MAILING ADDRESSS_________________________________________________

___________________________________________________________________

EMAIL ADDRESS ____________________________________________________

WEBSITE ___________________________________________________________

Describe your product or service(in a format to be added to website)

____________________________________________________________________

____________________________________________________________________

____________________________________________________________________

+++++++ Below this line for Administrative Use +++++

Paid $___________ for _______ year(s) membership @ $75 per year, for year _____.

Date Rec’d ________________________ by__________________________________

Return application and check to Kirk Smith, Affiliate Membership

Contact her at kirkv.smith@gmail.com or 919-573-8769