Name:

Title or Position:

Company Name:

Type of Business:

Business Address: Street: PO Box:

City or Township: State: Zip Code:

Business Phone No.: Fax No.:

Email Address: Web Site Address:

Home Address: Street: PO Box:

City or Township: State: Zip Code:

Home Phone No.:

Please indicate your areas of interest:
Audit Committe
Membership Committee
Booster/Civic Trust Awards
Program Committee
Community Weekend
Public Relations
Economic Development
Scholarship Committee
   
Date:
Signature: _______________________________
Please send this form along with your check for $50 to:

BIP, Inc.
c/o Virginia Rickert
P.O. Box 3494
Palmer, PA 18043