Eastern Section Membership Application

THIS FORM IS FOR JOINING ONLY THE EASTERN SECTION SEPM

THIS FORM IS TO BE USED FOR 2021

Membership Options

Eastern Section Dues - $8/year or one-time payment of $100 for Lifelong Membership

(use preferred mailing address)

First Name

Last Name

Date of Birth

Company

Street Address

Address (Cont.)

City

State/Province

Postal Code

Country

Phone Number

Fax Number

Email Address*

First name

Last name

Company

Address

Address 2

City

State

Zip

Country

Card type

Card number

Expiration month

Expiration year

CSC

Amount