Membership Application

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Membership Application

Company Name:

Name:

First Name MI Last Name

Address:

city state zip

Country:

Phone Number:

Fax Number:

Type of Business/SIC Code:

E-Mail Address:

Website Address:

Number of Employees:

Do you business Internationally?

Would you like to offer your products or
services to Member-to-Member Discount
Program?

do you want to be on our email list?

Where did you hear about us?

Select your Member Type:

	Membership Type	Annual Fee in US$
	President's Counselor	$10,000.00
	Member, Board of Advisor	$5,000.00
	Professional Membership	$1,500.00
	Business Member	$600.00
	Individual Member	$200.00
	Student Member	$75.00

You may supply a credit card number now that we will permanently keep on file, eliminating the need to type it in and send it over the internet with each order.

Payment Method:

Payment Amount:

Credit Card:

Card #:

Expiration Date:

Billing Contact:

Billing Address:

city state zip

Country:

If you choose to pay by mail, please mail your applicable fee to: Membership Dept., Pakistan International Chamber of Commerce, 2495 Eastgate Pl., Ste A, Snellville,

GA 30078

Membership fee are not tax deductible as a charitable contribution but a portion may be deductible as a business expense.

I hereby attest that the statements I have made are true to best of my knowledge, I agree to abide by the constitution and bylaws of PICC.

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