IBM Ecology Club - Membership form / updates

 

Type of Application :

[  ]  New Application        [  ]  Renewal                [  ]  Information update

Type of membership :

[  ]  Regular membership  $5.00                        [  ]  Deep Green membership  $20.00
Payment details :
Amount   $_______        Check # : ___________________
Employment details :
[  ]  Regular                       [  ]  Retireee            [  ]  Leave of Absence

 
INFORMATION
 First Name  
 Last Name  
 Home Address   
 City, State   Zip Code  
 Area Code/Telephone Number  
 Email Address  
 IBM Employee Number  
 
Make check payable to:   IBM Ecology Club

Mail form and check only to (or bring to meeting) :
Sushmita Senmajumdar
885 Lily Avenue
Cupertino, CA 95338

I hereby certify that I am currently an IBM employee, retiree, or on leave of absence. I also certify that I do not work at

an IBM location that is supported by any IBM Club other than the San Jose IBM Club.
Signature _______________________________________________________Employee No. ___________________  Date ____________
                                                 (Application MUST include applicant's signature and IBM employee number.)
 

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