ADVISORY COUNCIL MEMBERSHIP APPLICATION

2008-2009 NORTHEAST CONFERENCE YEAR

Please provide the following information and return with your check, credit card number, or purchase order to the address listed below.  Thank you!

INSTITUTION NAME/MAILING ADDRESS:

CONTACT PERSON OR REPRESENTATIVE:

PHONE ___________________________   FAX ___________________________E-MAIL ________________________________

PREVIOUS CONTACT PERSON OR REPRESENTATIVE (if applicable):____________________________________________

MEMBERSHIP CATEGORY:

 Advocate/Library Subscriber    $100.00                        

 Associate                             $200.00                        

METHOD OF PAYMENT (please circle):            check (payable to “Northeast Conference”)        Purchase order # _________

Visa/Mastercard  Credit card # |__|__|__|__|-|__|__|__|__|-|__|__|__|__|-|__|__|__|__|    Exp. date |__|__|__|__|__|__|

Print name as it appears on card____________________________ Signature_______________________________ Date___________

3-digit VIN# from back of card___________

Return to: NORTHEAST CONFERENCE ADVISORY COUNCIL

AT DICKINSON COLLEGE

PO BOX 1773

CARLISLE PA 17013-2896