New/Lapsed Membership Application Form

Protocol and Diplomacy International – Protocol Officers Association

NEW/LAPSED MEMBERSHIP APPLICATION FORM

DATE:

NAME:

(PREFIX/HONORIFIC, FIRST, MIDDLE, LAST/SURNAME, SUFFIX)

JOB TITLE:

ORGANIZATION:

ADDRESS:

CITY / STATE / ZIP / COUNTRY:

HOME PHONE: ( ) WORK PHONE: ( ) CELL: ( )

FAX: ( ) PRIMARY Phone Number (please check one): Home ___ Work ___ Cell ___

BUSINESS EMAIL:

PERSONAL EMAIL:

PRIMARY Email Address (please check one): Business ____ Personal ____

I agree to PDI-POA’s Code of Ethics. (A link to the Code of Ethics document is found on PDI-POA’s membership page – http://protocolinternational.org/membership.htm – in the Membership Application box at the right of the page.)

I give PDI-POA permission to list my name, title, affiliation & email address in the Members Only
section of the PDI-POA website as a way to introduce myself to current members Yes ____ No

I give PDI-POA permission to list my name, title & affiliation (with no contact information)
in the Public section of the PDI-POA website as a way of sharing with the public
the diversity of PDI-POA membership Yes ____ No

1.  _____ Membership Dues (for twelve (12) months from approval date) $200

2.  _____ New/Lapsed Member Application Processing Fee $50

PAYMENT:

Check# ______ (payable to PDI-POA)

OR Visa MasterCard

NAME ON CREDIT CARD:

BILLING ADDRESS (if different from above):

CREDIT CARD #:

EXPIRATION DATE: LAST 3 DIGITS ON BACK OF CARD:

PDI-POA is recognized as a tax exempt / non-profit trade association within the meaning of section 501 (c)(6)
of the United States Internal Revenue Service Code. Tax I.D. #20-0296867

How did you learn about PDI-POA?

Website Colleague (please provide name) Other

Send this page, résumé** payment to:

Monica Earley or by email to

VP for Membership, PDI-POA

908 Aloma Faye Ln **a resume is not necessary if you are renewing within

Ft. Walton Beach, FL 32547 USA two years of your last PDI-POA membership.