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-~5~ <br /> AMERICANPUBGCWORKSASSOOATION <br /> Your Campreheosive Public Works Resource <br /> Send Membership Payments to: Rep l a c e m e n t/Ad d i t i o n <br /> ' PO Box 802296 <br /> Kansas City, MO 64180-2296 <br /> Send Other Correspondence to: ~ o rm <br /> 2345 Grand Blvd, Suite 700 <br /> Kansas City, MO 64108-2625 <br /> 816-472-6100 • Fax: 816-472-1905 <br /> 800-848-APWA <br /> If you would like to replace or add a member to your group roster, please use this form and return with renewal <br /> j payment. Photocopies may be used if needed. Also identify any members which are to be removed from original <br /> ~ roster. <br /> 'i <br /> On the back of this form you will find an explanation of the types of membership available and the benefits included <br /> with membership. If your renewal notice reflects local chapter membership dues, these dues must be paid in order to <br /> ' maintain your local and national membership in APWA. <br /> if you have any questions regarding your group roster or you would like to 'verify the amount dtze for additions, call <br /> 1-800-848-APWA (or 8 i6-47z-6100 within Kansas City, Missouri metro area) or e-mail membershi~(a,apwa.net. <br /> If your Actual Roster Count is less than the Base Group If your Actual Roster Count is greater than the <br /> Count, you should add more names to your roster. No Base Group Count, your group is invoiced an <br /> additional fee will apply provided the Actual Roster additional member fee of $110 ($US) per person for <br /> Count is not greater than the Base Group Count. the difference. Chapter dues will also be affected.. <br /> AZ <br /> AR, , CA, CT, DC, MA, MD, MN, NC, NH, NJ, <br /> NY, OH, RI, TN, TX, UT, VA, VT, WA, and WI <br /> residents should contact APWA for details. <br /> ? Mr. ? Mrs.. M c1L~(A 0~ ~ ~ 1~ ~~1~ ~~l ~ <br /> ? Dr. ®`MS. Flrst Name Middle Initial Last Name P - fened Name {for badges) Title Y <br /> Organ ati (Age" y/Firm) Department/Division Office Address <br /> a1~10~ ~I(J ~~t~03 ~~(QO( 1~~~ ~ ~ui~ ~c~ . -~c~e~~v~: <br /> G~ ~ ~C~ ~ ~ <br /> Cit h <br /> Y State Zip+4 ork Phone Fax Work E-mail* <br /> Home Address (optional) HomJPhone (optional) Home E-mail (optional)* <br /> <br /> l Preferred Mailing Address: ? Home L! Office <br /> * E-mail addresses are only utilized for distributing APWA-related news and information. ~ <br /> ? Dc Ms. First Name Mi le initial st Nai Preferred Naane (for badges) Till yy~ ~ n r/ <br /> 1 V~ fit' <br /> ~ ~ wia~n~/ ~ os ~ <br /> Organization(Agen /Finn) Department/Division O~t~c~Address ~g2. <br /> ~ oZ fit(- 3~t ~f ~ Z ca~^la, ~ ~s n L ~t~ c~. euy'e~~o~ uti <br /> City Statc Zip+4 Work thone Fax Wor E-mail* <br /> Home Address (optional) ~ ~ Home Phone (optional) Home E-mail (optional)* <br /> Preferred Mailing Address: L~iHome ? Office <br /> * E-mail addresses are only utilized for distributing AP WA-related news and information_ <br /> <br />