Monte Jade Science and Technology (Southeastern U.S.)

Individual Membership Application/Renewal Form

NAME OF APPLICANT

 

SEX

DATE OF BIRTH

COMPANY NAME

POSITION

COMPANY ADDRESS

 

PHONE

FAX

HOME ADDRESS

 

HOME PHONE

EDUCATION

EXPERIENCE & EXPERTISE

 

APPLICATION DATE

SIGNATURE

(for office use only)

 

REMARKS

 

  1. Annul Membership Fee for Individual Member is \$25.00
  2. Annul Membership Fee for Student Member is \$15.00, Put down Student in Position column.
  3. Please complete this form and send with membership fee payment to: Mr. Sam Yen, PO BOX 81880, Atlanta, GA 30366, Tel: (678) 443-1646 Fax: (678) 443-1536
  4. Please make check payable to: Monte Jade Science and Technology Association (Southeaster US)
  5. Please notify us of your facsimile number changes as soon as possible.