Wsp Registrationform 09 - 10

The West Point Society of Philadelphia ANNUAL DIRECTORY AND REGISTRATION FORM 1 SEPTEMBER 2009 – 31 AUGUST 2010 Please use this form to remit your annual dues and bring current your information for publication in the Society’s Membership Directory. Unless indicated to the contrary in the space provided below, you hereby consent to the listing of your current information in the Society’s Membership Directory. Send your dues, MADE PAYABLE TO “THE WEST POINT SOCIETY OF PHILADELPHIA,” and completed application to: West Point Society of Philadelphia c/o Bill Belknap ‘81 845 Tremont Drive Downingtown, PA 19335 THE WEST POINT SOCIETY IS A “NOT FOR PROFIT ORGANIZATION” FORMED UNDER SECTION 501(C)(3) OF THE INTERNAL REVENUE CODE. MEMBERSHIP :

REGULAR

$40.00

SUSTAINING

$50.00

CURRENT STATUS:

ACTIVE DUTY RESERVES

BRIGADIER

$75.00

RETIRED

FIVE STAR

$150.00

CIVILIAN

CORPORATE

$500.00

RESIGNED

LIFE

$500.00

Check one

PLEASE COMPLETE THIS SECTION:

LAST NAME: _____________________ FIRST NAME: _____________ M.I.: __________, Rank__________ USMA CLASS:________; USNA Class__________, USAF Class_________; Other_________; Assoc. Mem___ CHECK HERE IF NO CHANGES FROM LAST DIRECTORY: HOME ADDRESS: ______________________________________________________________________ CITY: __________________________ STATE: ______ ZIP: ________-_______ HOME PHONE: ( ) _____________ CELL PHONE ( ) _____________, FAX ( )_________________ SPOUSE’S FIRST NAME: _____________________E-MAIL ADDRESS: _____________________________ CURRENT OCCUPATION: BUSINESS TITLE: _______________________ COMPANY NAME: _____________________________________ BUSINESS ADDRESS: ________________________________________________________________________ CITY: __________________________ STATE: ______ ZIP: ________-_______ BUSINESS PHONE: ( ) ________________ EXT.: _______ FAX NO.: ( ) ____________________ BUSINESS E-MAIL ADDRESS: ____________________________________________________________ TYPE OF BUSINESS: _______________________ I am willing to assist the Society with the following activities (CIRCLE ONE OR MORE): Founders’ Day Dinner

Membership

Assembly Articles

Advertising

Career Advisory Committee Programs

Networking Newsletter

Membership Directory Luncheon Speakers

CHECK HERE IF DO NOT CONSENT TO YOUR INFORMATON BEING LISTED IN THE DIRECTORY:

SIGNATURE: ________________________________________ DATE: ____________________________ NOTE: AN ASSOCIATE MEMBER’S INITIAL MEMBERSHIP APPLICATION REQUIRES THE ENDORSEMENT OF TWO USMA ALUMNI MEMBERS IN GOOD STANDING. _________________________________________

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ONLY MEMBERS WHO HAVE PAID HIS/HER DUES AND ARE OTHERWISE MEMBERS IN GOOD STANDING ARE ENTITLED TO RECEIVE A COPY OF THE SOCIETY’S DIRECTORY.

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