15 for 12 Fall Special

15 for 12 Fall Special - Member Form

Please complete this form for NEW members joining PHCC between October 2025 and December 2025.
Primary Contact

First NameLast NameSuffix
Job Title/Designation
1. Company Name:*
Phone number

Area CodePhone Number
Email address *
example@example.com
Business address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Website
Field of Work*
If Other:
New Member or Rejoin?
Membership Type*
State/Local Chapters*
Full Dues amount? (No installments on Fall Special)*
Please refer to the dues installment schedule
Your Name (chapter staff)*
Primary Contact

First NameLast NameSuffix
Job Title/Designation
2. Company Name:
Phone number

Area CodePhone Number
Email address
example@example.com
Business address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Website
Field of Work
If Other:
New Member or Rejoin?
Membership Type
State/Local Chapters
Full Dues amount? (No installments on Fall Special)
Please refer to the dues installment schedule
Primary Contact

First NameLast NameSuffix
Job Title/Designation
3. Company Name:
Phone number

Area CodePhone Number
Email address
example@example.com
Business address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Website
Field of Work
If Other:
New Member or Rejoin?
Membership Type
State/Local Chapters
Full Dues amount? (No installments on Fall Special)
Please refer to the dues installment schedule
Primary Contact

First NameLast NameSuffix
Job Title/Designation
4. Company Name:
Phone number

Area CodePhone Number
Email address
example@example.com
Business address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Website
Field of Work
If Other:
New Member or Rejoin?
Membership Type
State/Local Chapters
Full Dues amount? (No installments on Fall Special)
Please refer to the dues installment schedule
Primary Contact

First NameLast NameSuffix
Job Title/Designation
5. Company Name:
Phone number

Area CodePhone Number
Email address
example@example.com
Business address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Website
Field of Work
If Other:
New Member or Rejoin?
Membership Type
State/Local Chapters
Full Dues amount? (No installments on Fall Special)
Please refer to the dues installment schedule
Send payment through Versapay once new invoice has been uploaded into chapter portal

Please note that this has to be fully filled out for us to process the member(s).
Thank you!

Please press 'Submit' when done.
Should be Empty:

15 for 12 Fall Special - Member Form