DATE:
NAME: TITLE:
COMPANY: PRIMARY BUSINESS:
BUSINESS ADDRESS:
CITY: STATE: ZIP:
BUS. PHONE: BUS. FAX:
E-MAIL:
HOME ADDRESS:
CITY: STATE: ZIP:
HOME PHONE: HOME FAX:
E-MAIL:
MAILING PREFERENCE: HOME BUSINESS E-MAIL PREFERENCE: HOME BUSINESS
Please check here if you do not want AWNY to use your e-mail address for general mailings about our events and activities

YEARS AT PRESENT COMPANY:  YEARS IN COMMUNICATIONS INDUSTRY:

MEMBERSHIP PROFILE
EDUCATION:
COLLEGE: MAJOR:
2-YEAR COLLEGE 4-YEAR COLLEGE MASTERS DEGREE Ph D Other
OTHER PROFESSIONAL MEMBERSHIPS:
COMPANY TYPE:
Advertising Agency Advertiser/Client Broadcast/Cable Internet/Online Services Magazine
Newspaper Out of Home Public Relations
JOB FUNCTION:
Owner/Top Management Sales Marketing Production Media Creative
Programming Advertising Product Management Public Relations
OTHER (Please Specify)
Select the item in each category that best represents your situation (this section is optional)
AGE: UNDER 25 25 – 30 31 – 45 OVER 45
SALARY: UNDER $25,000 $25,001 – $35,000 $35,001 – $50,000 $50,001 – $75,000
$75,001 – $100,000 OVER $100,000

MEMBERSHIP CATEGORY
RESIDENT MEMBER Annual Dues: $125.00
($100 initiation fee applies)
SUPPORTING MEMBER Annual Dues: $150.00
($100 initiation fee applies)
YOUNG EXECUTIVE MEMBER (under 30)  Annual Dues: $65.00
ASSOCIATE MEMBER Annual Dues: $50.00*
NON-RESIDENT MEMBER Annual Dues: $50.00
Check here if reinstatement (initiation fee waived)
  Will the company reimburse you? Yes No
*Available only to former resident and nonresident members no longer engaged in the comunications industry


METHOD OF PAYMENT
        PERSONAL OR BUSINESS CHECK
Credit Card Number:
Expiration (Month/Year:) /

YOUNG EXECUTIVE APPLICANTS ONLY
Date of birth:

TYPE OF ID
If you were referred by someone, please indicate person's name here:
   

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Do not hit your Back or Refresh button during the Submit process.