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MEMBERSHIP ENROLLMENT
Fiscal Year (January 1,
2012 - December 31, 2012)
Contact Susan Weiss ~
Treasurer if you have any questions at
sweiss5@aol.com |
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Name: |
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Organization / Agency: |
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Address: |
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City, State, Zip Code: |
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Job Title: |
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Phone: Home / Work |
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Fax: |
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Email:
Pager: |
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MEMBERSHIP CATEGORIES
£
Organization
£ Agency
£ Individual
$20 a year OR $5.00 per
meeting/visit |
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- Make check payable to: DSSP
- Please print this membership form
and send it with your check to:
- Susan Weiss, Treasurer
- 2010 Vale St. ~ Champaign, IL
61822
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