NAME:           _________________________________________

CURRENT POSITION:_________________________________

AGENCY:_____________________________________________

MAILING ADDRESS:__________________________________

CITY/STATE/ZIP:______________________________________

BUSINESS TELEPHONE:______________________________

FAX NUMBER:_______________________________________

EMAIL ADDRESS:____________________________________

IPMA Certified:    _______Yes   ________No


IPMA/HR National Member _______Yes ________No


If yes, please include your ID # _____________________


 IPMA HR - CCC
Central California Chapter
Membership Application / Renewal

July 1, 2017 –June 30, 2018


Central California Chapter

MEMBERSHIP STATUS (check one):

RENEWAL ______    NEW MEMBER       ______

Referred by: _________________________________________

Chapter Dues:    $75  w/o Nat’l Membership

                                   Early Bird Special - $50 if paid 

                                   by 8/15/2017
                              $50 w/ proof of Nat’l Membership

                                    Early Bird Special - $25 if paid 

                                    by 8/15/2017
                              $15 Student Membership

Please make check payable to IPMA – CCC

Mail to:  IPMA - CCC
               c/o Norbela Luis
               PO BOX 3542
               Merced, CA  95344


www.ipma.ccc.org

Amount Paid:  $ _____________