HPGS Membership Application
Name
*
First Name
Last Name
Company / Organization
Address
*
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Phone Number
*
-
Area Code
Phone Number
Email
*
example@example.com
Website
Annual Dues Options (check one)
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( X )
Individual 65 and over
$
10.00
Individual under 25 years
$
20.00
Individual 26 to 64 years
$
80.00
Company / Organization (includes contact person)
$
100.00
Associate Member (individual of company member)
$
50.00
Total
$
0.00
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