Lifetime Member Registration
Member Name
*
First Name
Last Name
Member Email
*
example@example.com
Member Phone Number
*
Please enter a valid phone number.
Region
*
Region 1 - 7 Breakdown: https://www.shpe.org/membership/regions
Chapter Affiliation
*
Professional chapter you wish to belong to
Member Address
*
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Sponsor Information
(ignore if not applicable)
Sponsor 1 Name (if applicable)
First Name
Last Name
Sponsor 1 Email (if applicable)
example@example.com
Sponsor 1 Phone Number (if applicable)
Please enter a valid phone number.
Sponsor 2 Name
First Name
Last Name
Sponsor 2 Email
example@example.com
Sponsor 3 Name
First Name
Last Name
Sponsor 3 Email
example@example.com
Sponsor 4 Name
First Name
Last Name
Sponsor 4 Email
example@example.com
Payment Options
Pay in Full
Pay in (3) Installments
Pay in (4) Installments
Pay in (5) Installments
Signature
Date
-
Month
-
Day
Year
Date
Submit
Should be Empty:
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