Application for Wisrwa Membership

Application for WisRWA Membership

Date: ______

Name: ______

(Please use the same name as your RWA registration, if possible. To join WisRWA, you must be a member of RWA. Membership will be verified.)

Address: ______

City: ______State: ______Zip: ______

Telephone: ______

E-mail Address: ______

______Please add me to the WisRWA e-mail list

______It is okay to publish my e-mail address for member use only

______Please don’t publish my e-mail address

I am located in, or closest to, the following area:

______Chippewa Falls Area ______Milwaukee Area ______Wausau Area

______Greater Green Bay Area ______Madison/South Central Area ______Other

RWA PRO Member _____ RWA PAN Member _____

I am published in book length fiction: _____ Yes _____ No

Area of interest (i.e.: romantic suspense, single title, etc.): ______

I am published in the other following areas: ______

Pseudonym: ______

How would you like to be listed on the WisRWA member page?

_____Real name _____ Pseudonym _____Real name w/a pen name

I would be willing to volunteer for the following:

_____ Contest Category Coordinator _____ A newsletter article

_____ Contest Judge _____ Future Board Position

_____ Help with Conference _____ Present an Area Meeting Program

I understand the above information may, unless otherwise indicated, be published and used for the purposes of promoting WisRWA and will be available to all WisRWA members.

Member Signature: ______

Membership dues are $25.00 and cover the period between November 1 to October 31.

Dues paid between November 1, 2014 and Dues paid between May 1, 2015 and

April 30, 2015 will be renewable on October 31, 2015 will be renewable on

November 1, 2015. November 1, 2016.

Either, mail form and check to: or, email PayPal information and form to:

Jill Bevers PayPal amount ______

N98 W6125 Bristol Ln PayPal Transaction Number: ______

Cedarburg, WI 53012 Your PayPal email address: ______

Please make a nonrefundable check payable to WisRWA.

Dues not deductible as a charitable expense, but may be a business expense.

SECRETARY USE ONLY:

Date: ______Check #: ______Amt. $______Packet: ______

E-mail: ______Loops: ______DB: ______Author DB: ______