Affiliate Membership Application

Instructions

The Affiliate membership term is based on a calendar year from January 1 through December 31 and is not transferrable or refundable.

Select Your Option(s)

WeSERV Affiliate Membership

Enter Contact Information

Prefix (i.e. Mr. Mrs. Dr.)

First Name

Last Name

Suffix (i.e Jr. Sr. III)

Designations

E-mail

Family NameOffice Name

Please select a valid membership option and fee item if exist