PIWG Membership Application

Thank you for interest in PIWG!

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* Application Type

New Membership

Renewal

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* First Name

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* Last Name

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* Title

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* Organization

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* Address

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* Address 2

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* City

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* State

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* Zip Code

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* Phone

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* Email Address

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* Web Address

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* Brief Description of Organization or Department

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* Type of Membership

Vendor $750/Year

Academia $300/Year

Vendor $375/after 7-1

Academia $150/after 7-1

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* Payment Method

Credit Card (please use PayPal via PIWG website)

Check

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* If applicable, please provide Check Number

Thank you for applying!