application form I would like to join WHYPG as an individual memI would like to join WHYPG as a companysponsored member (The membership stays with my company.) first name
last name
contact info address PO Box 1420 Winter Haven, FL 33882-1420
company
phone
mailing address
863-293-2138
city
state
zip
phone
fax 863-297-5818
e-mail date of birth Yes, please include my contact information in the WHYPG membership directory. I have a Facebook account.
email will@winterhavenchamber.com
website
METHOD OF PAYMENT:
cash check visa master Make check payable to the Winter Haven Chamber Foundation. credit card # The WHYPG is affiliated with
name on the card: expiration date:
V-code:
signature
date
2012 Membership Application