Application for Membership

Name: ____________________________________________________________________

Title: _____________________________________________________________________

Company: _________________________________________________________________

Company Address: __________________________________________________________

Home Address: _____________________________________________________________

Work Phone: ____________________________ Fax: ______________________________

Home Phone: ______________________________________________________________

E-mail: ___________________________________________________________________

Website: __________________________________________________________________

Dues:
$30 per person Annual Members/$20 per person (five or more from same organization)
$10 per person for Student Members

Please return completed form(s) along with payment to:

Press Club of Southeast Texas
P.O. Box 1922
Beaumont, TX 77704-1922
Providing the information above keeps our records up-to-date and keeps you informed. Feel free to
print out copies of this form to recruit new members.

Questions? Contact Allison Howell, vice president for memberships at (409) 722-8279.

For Office Use Only

___/___/___ dues receipt date ___/___/___ check date

$ ______ amount __ personal check __ company check

Company _____________________________________

Membership effective date ___/___/___