PALM BEACH COUNTY PLANNING CONGRESS, INC.

2010 ONLINE MEMBERSHIP APPLICATION FORM

(Membership Year: New or Former Members - Date of Payment or Renewing Members
- January 1 Through December 31, 2010)

Please use this form to join or renew your membership or submit your form electronically at http://www.pbcplanningcongress.org/application.html. Our Member Directory and Mailing List are derived from the information on this form. Please fill out the Required Information (*) completely, even if you are a renewing member, to insure that our records are accurate and up to date. All Paid Members receive access to our on-line Membership Directory at our Web Site (www.pbcplanningcongress.org) using an individually assigned password.

Dues are still only $40 per year for our standard membership. Full time enrolled students can join for $10 per year.¹ Dues can be paid electronically by credit/debit card, check or cash via the Pay Pal link on our website at www.pbcplanningcongress.org or mailed to the PBC Planning Congress at PO Box 1371, West Palm Beach, FL 33402.

Please Check One New Member Renewing
First Name*	Middle	Last Name*	Professional Designation(s) (AICP, PE, ASLA, Esq., PMP, PG, etc.)
Position/Job Title
Department
Agency/Firm
Primary Address: Address*
City*	State* Alabama Alaska Arizona Arkansas Armed Forces (USA) California Colorado Connecticut Delaware District of Columbia Florida Georgia Guam Hawaii Idaho Illinois Indiana Iowa Kansas Kentucky Louisiana Maine Maryland Massachusetts Michigan Minnesota Mississippi Missouri Montana Nebraska Nevada New Hampshire New Jersey New Mexico New York North Carolina North Dakota Ohio Oklahoma Oregon Pennsylvania Puerto Rico Rhode Island South Carolina South Dakota Tennessee Texas Utah Vermont Virgin Islands Virginia Washington West Virginia Wisconsin Wyoming		ZIP/Postal Code*
Mailing Address (if different from above): Address
City	State Alabama Alaska Arizona Arkansas Armed Forces (USA) California Colorado Connecticut Delaware District of Columbia Florida Georgia Guam Hawaii Idaho Illinois Indiana Iowa Kansas Kentucky Louisiana Maine Maryland Massachusetts Michigan Minnesota Mississippi Missouri Montana Nebraska Nevada New Hampshire New Jersey New Mexico New York North Carolina North Dakota Ohio Oklahoma Oregon Pennsylvania Puerto Rico Rhode Island South Carolina South Dakota Tennessee Texas Utah Vermont Virgin Islands Virginia Washington West Virginia Wisconsin Wyoming		ZIP/Postal Code
Work Phone:	Work Fax:
Home Phone:		Cell:
Primary email address*
Secondary email address (where you would ALSO like to receive email from the PBCPC) Secondary address and secondary email address will NOT be listed in the Directory Data Base.
Agency/Firm Website
Contact Me About Co-sponsoring an Event Yes No
Suggested Programs for the upcoming Year
I prefer to receive a printed Newsletter via U.S. Mail. Yes No I prefer NOT to display the following in the PBCPC directory: employer: address: work phone: home phone: cell phone:
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* Required information