Membership Form

 DVAPT Membership Form

(Please type or print clearly)
                                      


First Name:___________________ Last Name_______________________

Position/Title__________________________________________________

Employer_____________________________________________________

Mailing Address:

Street Address_________________________________________________

Apt. Number___________

City________________________ State________ Zip Code_____________

Phone___________________________________

Cell Phone_______________________________

Email Primary_____________________________@___________________

Email Secondary___________________________@___________________

DVAPT membership fee: $45.00**

As a chapter member, you will also become an “Associate Member” of APTi

Please enclose a check payable to “DVAPT” and mail to:

DVAPT

7932 Green Lane

Wyncote, PA 19095

**If you already belong to APTi, you may add chapter membership by sending
documentation and a check for $30 payable to “DVAPT”. Please also respond
 to the following:

    I joined APT International for the membership year through (date)  _____________. 
    I joined as a:

                 “Professional Member” (paid $110 to APTi)
         “Retired Member” (paid $75 to APTi)
            “Student Member” (paid $55 to APTi)