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Adam <br />Send Membership Payments to <br />PO Box 802289 <br />Kansas qty, MO 541903286 <br />Send Other correspondence to: <br />2345 Grand BNd4 SUVA 700 <br />Kanses CVy, MO 64105.7626 <br />610472-8100 • Fnc 918472.1805 <br />900.84SAMA ' <br />Replacement/Addition. <br />Form . <br />Ifyou would like to replace or add a member to your group roster, please use this form and return with renewal <br />payment. Photocopies may be used if needed, Also identify any members which are to be removed from original <br />roster. - - <br />On the back of this form you will find an explanation of the types of membembip 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 anyquestions regarding your group roster or you would like to verify the amount due for additions, call <br />1-800-848-APWA (or 816-472-6100 within Kansas City, Missouri metro area) or e-mail malbadillQMm. <br />If your Actual Roster Count is less than the Base Group <br />Count, you should add more names to your roster. No <br />additional fee will apply provided the Actual Roster <br />Count is not greater than the Base Group Count <br />If your Actual Roster Count i9 greater than the <br />Base Group Ceunf, your group is invoiced an <br />additional member fee of $116 ($US) per person for <br />the difference. Chapter dues will also be affected. <br />AR, AZ, CA, CT, DC, IL, MA, MD, MN, NC, NH, <br />NJ, NY, OIL Rr, TN, TX, UT, VA, VT, WA, and <br />WI residents should contact APWA for details. <br />Group ID Number 2)5 <br />I <br />our. ❑ Mrs. Kathryn P. Brotherton. Kathryn, Assistant City Attorney <br />D Dr. 91 Ms. Fiat Name Middle Initial Last Name Prefornd Name (for badges) 79t1e <br />City of Eugene, City Attorney's Office, 777 Pearl Street, Rm 105 <br />OWniaaon (AgeneylFinn) Departmoo (vision Office Add= <br />Eugene, OR 97401 (541)682-5344; (541) 682-5414; )Cathryn.brotherton(dci.eugene.or.us <br />City state Zip+4 Work Phone Fax Work E-mail. <br />Home Address (optional) Home Phone (optional) Home S m tl (optional)' <br />Preferred Mailing Address: ❑ Home ® Office Birth Year. 1972 <br />• E-mail addresses are only utilized for distributing APWMrelated news and information. <br />® U Mr. O Mrs. <br />❑ Dr. O Ms. Fat Name Middle initial Mast Now Preferred Name (for badges) 75tle <br />OWnintion (Agency/ i m) Depamnemovision OiBx Addtew <br />'City stati Zip+4 Work Phone' Fax Work a-mail• <br />Home Address (opamal) Home Phone (optional) Home s-mail (optional)' <br />Preferred Mailing Address: ❑ Home ❑ Office Birth Year: <br />• E-mail addresses are only utilized for distributing APWA-related news and information. <br />