PRINT THIS FORM AND MAIL IT WITH YOUR CHECK TO JOIN THE FORT WAYNE RUBBER AND PLASTICS GROUP
CLICK  [HERE]  TO JOIN ONLINE WITH CREDIT CARD

Fort Wayne Rubber & Plastics Group, Inc.
INVOICE FOR 2005/2006 YEAR

ANNUAL DUES $10.00. MAKE CHECK PAYABLE TO FORT WAYNE RUBBER GROUP INC.

RETURN THIS INVOICE ALONG WITH YOUR CHECK

YOU MAY PAY FOR 1 TO 3 YEARS MEMBERSHIP
PLEASE CIRCLE:   ONE YEAR/$10.00    TWO YEARS $20.00    THREE YEARS/$30.00

MAIL TO:
 Greg Diederich, 20850 Armada Ridge, Armada, MI  48005
PLEASE PRINT LEGIBLY OR TYPE
NAME:________________________________________________________________________
CIRCLE PREFERRED MAILING ADDRESS:             HOME             BUSINESS

HOME ADDRESS
____________________________________________

____________________________________________

____________________________________________

____________________________________________

BUSINESS ADDRESS
____________________________________________

____________________________________________

____________________________________________

____________________________________________
HOME PHONE:__________________________     FAX:____________________________  
BUSINESS PHONE:________________________________
EMAIL ADDRESS:________________________________________________

CHECK APPROPRIATE MEMBERSHIPS
[  ] AMERICAN CHEMICAL SOCIETY
[  ] RUBBER DIVISION, A.C.S
[  ] RMA		 SUPPLIER OR MANUFACTURER?
[  ] SUPPLIER TO THE INDUSTRY
[  ] MANUFACTURER

PLEASE NOTE IF YOU WOULD LIKE TO PARTICIPATE ON A COMMITTEE:
_______________________________________________________
_______________________________________________________
_______________________________________________________

OFFICIAL USE ONLY
DATE: ________________
CARD NUMBER: _______
MEMBER:       O       N
ENV. PROV.   YES    NO
CHECK #: _____________
Home Programs Calendar Officers Feedback Fun Stuff