Membership Application

Chinese Professional Club Membership Application/Renewal


		$100 Lifetime Single				$200 Lifetime Family

		$10 Single Annual				$20 Family Annual

		Renewal				Information Change


Salutation:	Mr.____	Mrs. ___	Ms. ___	Mr. & Mrs. ___		Dr.___	Drs.___

	Dr. & Mrs. ___		Mr. & Dr. ___		Other ____

Name(s):

Address:

City: _______________________			State: _________		Zip Code: ___________________

Telephone:	Home:				Home Fax:

	Work:				Work Fax:

E-Address:

Profession(s):

Alma Mater(s)_________________________________________________________________________

Referred by:___________________________________________________________________________
Please complete and remit this form & dues to: Anna Au, 63 Tiel Way, Houston, TX 77019
Please make checks payable to: Chinese Professional Club.

AMOUNT ENCLOSED:		$


CASH: ______ CHECK: ______ DATE PAID: ____________________