Membership / Sponsorship Form

Individual / Company Name
Contact Name * First Last
Title
Address *
Street Address

Address Line 2

City

State / Province / Region

Postal / Zip Code

Country
Phone * - (###) - ### ####
Fax - (###) - ### ####
Email Address *
Membership Fees * Sponsorship ($200)* Membership Only ($25)
*$200 YEARLY SPONSORSHIP: Includes membership, advertising on our meeting flyer notifications, recognition at our Annual Holiday Meeting, and advertising opportunity on each table, five times a year. Please provide the copy.

Please Make Checks Payable To:
Professionals in Workers' Compensation
c/o Jennifer Flood
614 Ironwood Dr. SE
Salem, OR 97306

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