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APT DC Membership Form - Page 1 of 2

Primary Contact Name * First Last
Firm/Organization
Website
Title
Field/Profession *
Address *

Street Address

Address Line 2

City

State / Province / Region

Postal / Zip Code

Country
Work Phone * - (###) - ### ####
Email *
Yes, I/we wish to join APT DC at the following level of membership: * Individual Member $25 Student Member (provide photocopy of ID) $10 Family/Dual Member $40 (1 Primary, 1 Secondary) A+ Friend $100 A+ Sponsor $250 (1 Primary, 1 Secondary) A+ Patron $500 (1 Primary, 2 Secondary)
I am a: * Renewing APT DC Member New APT DC Member
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