Recipient First Name *  

Recipient Last Name *  

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Company Name  

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City *  

State * ALAKAZARCACOCTDEDCFLGAHIIDILINIAKSKYLAMEMDMAMIMIMSMOMTNENVNHNJNMNYNCNDOHOKORPARISCSDTNTXUTVTVAWAWVWIWY  Zip Code 

Phone *  

Phone type  HomeCellWorkOther

E-mail  

The Council sends regular e-mail broadcast newsletters on upcoming programs, travel opportunities and membership benefits and reminders. Your recipient's e-mail address is important to us to insure that they are kept up to date on Council events and short-notice updates/advisories on programs. They will be automatically added to our e-mail subscriber list for this reason. However, if they do NOT wish to receive any e-mail from the Council, they may unsubscribe at any time by sending an e-mail to membership@wacphila.org.

Family Members' Names (if applicable): *Please indicate relationship

  I am a Young Professional between the ages of 21 and 35. Please send me information about Young Professionals events.

My name (gift-giver):  

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State * ALAKAZARCACOCTDEDCFLGAHIIDILINIAKSKYLAMEMDMAMIMIMSMOMTNENVNHNJNMNYNCNDOHOKORPARISCSDTNTXUTVTVAWAWVWIWY  Zip Code 

Phone *  

Phone type  HomeCellWorkOther

E-mail  

My current level of membership is:  Individual  Dual  Dual Plus  Ambassador  Cabinet  Statesman  Premier  Superpower

I wish to give a membership at this level (please check one yearly fee): *Please select a Level

Individual (formerly Delegate) — $60
Dual (formerly Diplomat) — $100
Dual Plus (formerly Envoy) — $250
Ambassador — $500
Cabinet — $1000
Statesman — $2500
Premier — $5000
Superpower — $10,000

Click here to view all membership levels

Please include the following message with my gift:

You are welcome to use this online form to purchase your referral or gift membership by completing the information — including your credit card number — and selecting SUBMIT below.

You may prefer to print this form and mail it to the Council along with your credit card number or check.

Credit Card Type *   Visa
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SIC/"V" Code   Click here to view SIC/V location

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How did you initially find out about membership to the Council? *Please check one