Membership Form

Member Application

		WOMEN IN ELECTRONICS, INC.
		ATLANTA CHAPTER
		P.O. Box 956213
		Duluth, GA 30095
		Telephone: (404) 281-8766
		Email: sgray@spectralresponse.com or skatacinski@spectralresponse.com

Date:

Your Name:

Birthday: (Month/Day)

Home Address:

City, State, Zip:

Home Phone:

Home Email:

Business Name:

Title:

Business Address:

City, State, Zip:

Business Phone:

Fax:

Business Email:

Important! Please specify where to send your membership confirmation and any other WIE communications.

Business Address and email

Home Address and email

MEMBERSHIP OPTIONS. Please check one.

Annual Membership, $25.00

Student Membership, $12.50

Renewal for

1 year

2 years

_____ years

Please bring to a WIE meeting or Mail this form with payment to:

Women In Electronics, P.O. Box 956213, Duluth, GA

30095

We are happy to have you join our dynamic group.