NEW MEMBERSHIP AND RENEWAL APPLICATION

(Print Out and Send In)

NAME:_____________________________________ 

TITLE:_____________________________________

AGENCY NAME:____________________________________________________________

AGENCY ADDRESS:_________________________________________________________

CITY/TOWN:_______________________________ STATE:________ZIP:_____________

BUSINESS PHONE: (____)__________________  FAX: (____)______________________

HOME ADDRESS:__________________________________________________________

CITY/TOWN:_______________________________ STATE:________ ZIP:____________

HOME PHONE: (____)__________________     E-MAIL:__________________________

MAILING PREFERENCE:   HOME______  OFFICE ______  FAX______

TYPE OF MEMBERSHIP:   Active     Associate     Corporate     Affiliate     Agency   

           (Circle one)

CURRENT CRIME PREVENTION ACTIVITIES:________________________________

__________________________________________________________________________ 

1.  Have you attended the New York State Basic Crime Prevention School? Yes__  No__

     If yes,  where and when?______________________________    Hours attended:______

2.  Sponsor Requirements/Name(s):  Associate- 1 active member; Affiliate- 2 active members;

     Agency- 1 active member; Corporate- 2 active/associate members

NAME:__________________________________

PHONE:_________________________________AGENCY:_________________________

NAME:__________________________________

PHONE:_________________________________AGENCY:_________________________

RETURN APPLICATION (with appropriate dues) TO:

CPA WNY