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2007 - 2008 Membership Application

APPLICATION PROCEDURE:

1. Fill out all information in the fields below.
2. Applicant’s eligibility must be certified by a Principal Member of the WCPA.
3. Applicant shall submit proper dues payment at time of application.
4. Notice of application shall be published in the Official WCPA publication.
5. If no valid written objections are received within 60 days after publication, the applicant will be duly accepted as a member.

Applicant Information:

First Name:

Last Name:

Department / Agency:

Rank / Title:

***Email:

***Will Also be used as your login username upon membership approval

Phone:

Fax:

Agency Information:

Address:

Address 2:

City / State / Zip:

Biographical Information:

Date of Birth:

/ / i.e.. 07/07/2007

Age:

Education:

High School

A.D.

B.S.

M.D.

Membership Information:

Classification of Membership Desired (choose one):

Principal
Associate
Affiliate
Retired

WCPA Sponsor :

Applicant Digital Signature:

Please type your full name to serve as your signature

I Accept
By clicking "I Accept" you acknowledge that the above name is to be linked to your application and shall hold the same value as your legal signature. Also by checking this box you attest to the above information as true and current to the best of your knowledge on the date and time of this application.

After completion:
After completion of this form please send application fees to:
(for for further information contact also:)

Executive Director Don L. Thaves
1141 S. Main St.
Shawano, WI 54166
Phone: (715) 524-8283
info@wichiefs.org

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