Application Form

Licking County Computer Society Application Form

This form may printed out and used for paying membership dues ( new/renewal ).

Check one: ___ New Membership ___ Renewal

Set your browser's font size to medium or larger and it should print to a single page. Please fill out all applicable sections and submit this page to the address below.

Date:____________

Name:________________________________

Home Phone:________________________

Address:_________________________________

E-Mail:_________________________

City, State, Zip:____________________________________________________________

Place of Business (optional) ______________________________

Phone No. _______________

Computers you now use: Check all that apply

___ PC (IBM Compatible) ___ Macintosh ___ Other ___ None

Dues ( Please check one )

___ Single $24.00	___ Family $36.00
___ Student ( full time ) $12.00	___ Sustaining ( life ) $250.00
___ Small Business ( 0-50 employees )	___ Large Business (50+ employees)
$75.00 + $20.00 for each employee.	$150.00 + $20.00 for each employee.

Please send your check with this entire form to:

Licking County Computer Society

Treasurer

PO Box 612, Newark, Ohio, 43058-0612

Newark, Ohio 43055

Please note: The Licking County Computer Society does not endorse or condone any use of software that violates the software’s license agreement.

For Office use Only:

___ Updated database

___ Sent membership card & Bylaws

___ Sent new member name to RB

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