MEMBERSHIP APPLICATION

IMPORTANT: Even if your membership mailing information has not changed please complete the following:

NAME _______________________________ CPA CERTIFICATE #___________

ADDRESS ____________________________ STATE _______________________

_______________________ ____ ________ DATE ISSUED ________________

PHONE (W) ___________________________ PHONE (H) ___________________

COMPANY ___________________________ JOB TITLE ___________________

CO. ADDRESS ________________________ PUBLIC ____ OR PRIVATE ____

_______________________ ____ ________ GRADUATE OF & DEGREE(S)

**E-MAIL ____________________________ _____________________________

**WE SEND A MAJORITY OF OUR CORRESPONDENCE VIA E-MAIL. PLEASE PROVIDE US WITH THE E-MAIL ADDRESS WHERE YOU PREFER TO RECEIVE CORRESPONDENCE.

MAIL TO BE SENT TO ________ HOME OR ________ BUSINESS

BIRTHDATE _________________ ANNIVERSARY _________________

Indicate the committees you are interested in:

_____ Career Development _____ Public Relations/Newsletter _____ Membership

_____ Special Projects _____ Speakers/Programs _____ Student Affairs

Type of Membership: _____ Full Member (CPAs only) -- $50

_____ Associate Membership (open to all Professionals) -- $50

_____ Student Membership (open to accounting students) -- $10

Annual Dues are from October 1^st through September 30^th. Please make check payable to St. Louis Society of Women CPAs or SLWCPA.