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<br />) <br /> <br />GFOA Membership Application Form <br /> <br />If paying by check, please send directly to: <br />Government Finance Officers Association <br />Dept 77-3076 <br />Chicago, IL 60678-3076 <br /> <br />If paying by purchase order or by credit card, please <br />mail or fax to: <br />Government Finance Officers Association <br />203 North laSalle Street, Suite 2700 <br />Chicago, IL 60601-1210 <br />Phone:312f977-9700 fax: 3121977~06 <br /> <br />Employer <br /> <br />r:~ 6 Cp~V',((~ <br />\ 8' ~c VVl.4 ('" s;:t'v\~J. <br />rp A-k.Y\. v: l (.f <br />USA <br />~~ l - <.(~ct - ~23 L <br /> <br />Address <br /> <br />City <br /> <br />fvttU <br />State/Province <br /> <br />55o'l S <br />ZipIPostal Code <br /> <br />Country <br /> <br />Phone <br /> <br /><oS{ - {1.~ -8~ 2~ <br /> <br />Fax <br /> <br />~Lue~.,.. erf'~A..V~II'M"" ..c.~......... <br />-J Mall <br /> <br />,?6Payment of $ t9lJ. DD enclosed. <br /> <br />~Please bill me for membership. Purchase order number J/P I' <br /> <br />Q Please charge my credit card: <br />Q American Express Q Diner's Club Q Discover Card Q MasterCard a Visa <br /> <br />Account number <br /> <br />Expiration date (required) <br /> <br />Signature (required) <br />Note: u.s. membet:s pay their membership fees in u.s. doUars; Canadian membem pay their fees in Canadian dollars. <br /> <br />Member Types (ct.k one) <br />~ctive a Ad~itional Active Q Associate <br />. (ifjiJt.time sIUtkra. p/eme ~ a copy 11/ SIUtlmt itlmtifi=ion -a; <br /> <br />Q Educational <br /> <br />Q Inactive Retired <br /> <br />Governmental Unit (ill th.: U,li:ed Stata or CanodaJ <br />Refer to attached GFOA Membership Fee Schedule (Check one and give size of unit, as requested) <br /> <br />~ity: Population <br />Q County: Population <br />Q Special district: Number of employees <br /> <br />3laoo <br /> <br />a State/Province: Population <br />a Retirement system: Number of members <br />Q Federal <br /> <br />International (OIlI>iJ, rif "" United Suer and C4wJd.1) <br />o DEll!.elgped CQURtr:y .0 De."eloping Country <br /> <br />o 1I~5ociai:e <br /> <br />p;d <br />