2012 INTELLENET MEMBERSHIP RENEWAL

1 January 12 to 31 December 12

Amount Due:   $125.00

Due NLT 30 April 2012

RETURN THIS SHEET WITH PAYMENT

YOUR NAME: _____________________________

(Please print name)

Verify your contact information, specialized skills and language proficiencies as listed on the Membership List section of http://www.intellenetwork.org website.

NOTE: (DO NOT FILL IN UNLESS A LISTING CHANGE IS NEEDED.)

ADDRESS: ______________________________________________________________

_________________________________________________________________________

_________________________________________________________________________

PHONE: ______________ FAX: ______________ EMAIL: _______________________

Please use reverse for COMMENTS or contact intellenet@intellenetwork.org with questions.

NOTE: Prior Agency _____________________ (Fed, State or local I.E. agency if application.)

PAYMENT OPTIONS:  (Please Print Legibly)

[ ] Credit Card:   ____ Visa  ____ MasterCard  ____ American Express  ____ Discover
     Card #: __________________________  Exp. Date: ____/____  Security Code: _____
     Card Holder's Name: _____________________________________ (as it appears on card)
     Billing Address: ________________________________________________________
     City:_________________________________  State: ________  Postal Code: _______

[ ] Check: ALL CHECKS MUST BE DRAWN ON U.S. BANKS
                   Make checks out to Intellenet and send to:

Mail to: Intellenet

P.O. Box 350

Gladwyne, PA 19035

USA

Thank you for your renewal!         

PLEASE ACKNOWLEDGE THIS

[ ]   I renew my pledge to abide by our Code of Ethics and Bylaws. (Latest version on website.)