Clone of Join the BWLC

Membership Form

Xerox Employees, Friends of BWLC and Ally
Payroll Deduction and Paypal are available to all Xerox employees. "Friends of BWLC" and Ally memberships are available via Paypal.
Date Joined

Month Day Year
What Year *

This Year
Name *

First Last
E-mail *
example@example.com
Phone (000-000-0000)
Address

Street Address

Street Address Line 2

City State / Province

Postal / Zip Code Country
Payment Method *

Payroll Deduction (Xerox Employees) PayPal (Xerox Employees) PayPal (non-Xerox Employees) PayPal (Ally)
Member Level - Payroll Deduction

$25: Xerox Technology Employee $25: Xerox Services Employee (Employee of a Wholly Owned Subsidiary/Affiliate) $35 BWLC Ally
Membership Level - Pay Pal
prev next ( X )
Xerox Employee $ 25.00

Employee of a Wholly Owned Xerox Subsidiary or Affiliate $ 25.00

Friends of BWLC $ 35.00

BWLC Ally $ 35.00
Employee ID
Title
Division or Organization
Job Field
Employee Status

Exempt Non-Exempt Intern/Co-op
Friends or Ally Type

Xerox Employee Xerox Retiree Contractor Family Member Friend
Years of Service
Education Level
Age Range
Birth Month
Birth Day
How would you like to serve in BWLC?
How did you hear about the BWLC?
BWLC Chapter *

California & Northwest Region (incl. AK, AZ, CA, HI, ID, MT,NV, OR, UT, WA, WY) Central Southwest Region (incl. AR, CO, KS, LA, MO, NE, NM, OK, TX) Mid-Atlantic Region (incl. DC,DE, MD, VA, WV) Monroe County (incl. Buffalo) Northeast Region (incl. CT,KY, MA, ME, NH, NJ, NYC, OH, PA, RI, VT) Southeast Region (incl. AL,FL, GA, MS, NC, SC, TN) Midwest Region (incl. IA, IL,IN, MI, MN, ND, SD, WI, Ontario, CA)
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Membership Form