Membership Application

Submitted by cmayberry on Wed, 04/06/2011 - 08:07

Interested in joining WIB Winona? Please fill out the registration form below. A member of the board will contact you within 1 month once your membership is processed. Please contact wibmembership@wibwinona.org with any questions.

Date: *

Name: *

last, First, Middle Initial

Employer: *

Title/Position: *

Work Address: *

Work Phone: *

Contact Email: *

Address you would like to receive your monthly event invitation, surveys and quarterly newsletters.

Home Address: *

Home Phone: *

Special Interests:

Suggestions:

Sub-Committee:

Would you be interested in joining any of the sub-committees listed below? Please check all that apply.

Referral Information:

If you were referred please list who referred you.

Would you like to order a name tag?: *

Pin Back ($6.00)

Magnet Back ($7.00)

None

Please select the type of name tag or none if you would prefer not to purchase one.

Name as you would like it to appear on your name tag (if applicable):

Please type your name exactly as you would like it to appear on your name tag.