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Membership Form
I am a:
New Member Join Date
Renewing Member's Original Join Date
Name of Club
Member's Name
Member's Address
Member's City
Ph. Numbers (Home)
Ph. Numbers (Work)
Ph. Numbers (Cell)

(Please Keep members Email address current; this is the main form of communications between BPW/NC and members.)

(If your Email changes during the year please contact Webmaster for assistance in updating it.)

If Employed, Name of Employer and Position Held/Job Title
*May You be Contacted at place of employement if need? (Yes or No)your full name
New Members: Person who told you about BPW

State Dues - $25 | Club Dues - $35  |  Total Dues - $60


Print and Mail Completed Form and Check to: PO Box 5800 Concord, NC 28025