Portlandia Club Inc. Membership Application

Section 1: Contact Information

First and Last Name: *

Home Phone:

Cell Phone:

Business Phone:

Email Address:

I wish to receive communication from Portlandia via: *

Regular Mail

Mailing Address: *

Mailing address is Home Address

Mailing address is Business Address

Company:

Street: *

City: *

State: *

Zip: *

Section 2: Background Information

Job Title: *

Job Description: *

Education (School, Degree, Area of Study): *

Organizations:

Areas of Knowledge: *

Leisure Activities: *

Section 3: Member Information

Birthdate (Day): *

Birthdate (Month): *

Spouse / Mate:

Reason for Joining: *

Referred by:

Section 4: Club Information

Please read and check to indicate that you have read the club information: *

We are pleased you have chosen to become a member of Portlandia Club, Inc. This member application collects biographical information about you and communicates our fees and dues. This information will be published in the Portlandia online as your member profile. After your application has been processed you will receive more information about the club and how to get the most out of your membership from our membership chair.

We ask each of our members to serve on at least one committee to give you the opportunity to get to know other members and to contribute to the continuation and success of our organization. Included in the information you will be receiving will be a list of all of our committees. Those actively seeking new members will be highlighted. Once you select the committees) you wish to join, the chair of the committees) will contact you to inform you of the duties and responsibilities of the committee, the time commitment involved, and to answer any questions you may have regarding your participation.

Section 5: Fees and dues

Annual Dues:
Dues are established by the Board of Directors. Annual dues are $150.00.

New Member Fees and Dues:
Your dues are prorated for the quarter in which you join:

Quarter	Dues	Initiation Fee	Total
January - March	$150.00	$50.00	$200.00
April - June	$112.50	$50.00	$162.50
July - September	$75.00	$50.00	$125.00
October - December	$37.50	$50.00	$87.50

Reinstatement Fee and Dues:
Your dues are prorated for the quarter in which you join:

Quarter	Dues	Initiation Fee	Total
January - March	$150.00	$25.00	$175.00
April - June	$112.50	$25.00	$137.50
July - September	$75.00	$25.00	$100.00
October - December	$37.50	$25.00	$62.50

Corporate Membership:
Please contact the Director of Membership if you are joining with more than 4 other applicants, Marilyn Mays

Please ensure the form is fully filled and press the Submit button. You will have the opportunity to mail your payment to Portlandia Club Inc. or pay online.

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