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2010 Membership Application
 

Type

Renewal
Prior to Jan.31

Renewal
After Jan. 31

*New Member
Active $40.00 $50.00 $45.00
Associate $35.00 $45.00 $40.00
Student $20.00 $30.00 $20.00
Sustaining $100.00 $100.00 $100.00
Honorary $0.00 $0.00 $0.00

*New Member = Not a member in the last calendar year

If you are a current member and need to make changes to your membership profile, please email us at webmaster@pacr.org.

* Required Information

*Submission Type:

Renewal New

*Membership Type:

Active Associate Sustaining Student
Honorary Honorary Life
Membership ID:
*First Name:
*Last Name:
Credentials:
Title:
Home Street Address:
Home Street Address (cont'd):
City:

State:

Zip Code:

Home Phone:
Hospital / Organization:
Business Street Address:
Business Street Address (cont'd):
City:

 

State:

Zip Code:

Business Phone:
*Preferred Address:

 Home Business
*E-mail:


If you do not have an email address, please enter "none" above.

*Would you like to be published in the PACR Membership Directory?  Your job title, hospital/organization, business phone number and address, and email will be listed.

 Yes  No

* Photo Release:  I hereby give permission for PACR to utilize my photo taken at PACR functions for promotional reasons and this constitutes electronic signature.

         Yes  No

If you are interested in becoming more involved with PACR, select your interest areas below.  Select one or more.

Elected Officers:      
President-Elect Vice President Secretary Treasurer
Appointed Committee Chairs:
Bylaws/Historian Education Legislative Membership
Nominating Program Public and Media Relations

Comments 

I have reviewed and acknowledge acceptance of the PACR Terms and Conditions.

*  

Payment options include: Credit card and check

 

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