Member Registration

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	"Established 1985, FAPAC is the oldest and most active organization of Asian Pacific Americans in Government."

Member Registration

Personal Information :

Prefix

Other

First Name *

Last Name *

Middle Initial

Suffix

Other

Home Email Address *

Mobile No

Home Phone No. *

Fax No.

Home Address *

City *

State *

Zip Code *

Office Information :

Agency/Company *

Other

Type of Employment *

Other

Position Title

National Origin

Employment Status *

Office Mailing Address
(street, city, state)

Office Zip Code

Office Email Address*

Office Phone No.

Other Information :

I am interested in joining the following working committees (please select applicable front column(s)):

Annual Dues (check X in appropriate category column) start October 1. If join before or after October, dues are pro-rated by month (i.e., $3/month for a regular member, $2/month for an associate member). Except life time members , all other members are renewed annually with dues paying. The membership dues are to be paid October 1 of each year.

Regular Member (Current employees)		$36/year per applicant		$300 lifetime member per applicant
Associate Member (Retirees & Others)		$24/year per applicant		$150 lifetime member per applicant

I certify that the information provided on this form is true and correct to the best of my knowledge. I understand that falsification of information on this form may be grounds for denying the FAPAC membership.

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