METRO CABSE MEMBERSHIP FORM

          _________________________________________   

Name (Mr./ Mrs. Ms /PhD / EdD)

_________________________________________

Current Position / Building Assignment/Institution

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Employer

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Home Address                 

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City                          State           Zip 

                                                                                  .                                                                                                                                                                                                        

Home Phone                            Work

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E-mail                       Fax

Interest,  Indicate on Reverse Side

Membership:          New                 Renewal

   $35.00 Local and State Membership

        $25.00 Retired Educator &

       Full Time Students  -- Local and State

        $300.00 Local Life Member Dues

        $100.00 National (yearly)

Make checks payable to:  METRO CABSE

Amount enclosed: $ ________    ________                                                                                                                                Date

Referred by _______________________

Send form and dues to:

Metro CABSE

P.O. Box 5496

Cleveland, Ohio 44101-1681