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    Individual - Application - Rate Increase

    Uploaded by

    Ursula Johnson
    Thank you for the information. I will keep your membership details confidential.

    Copyright:

    Attribution Non-Commercial (BY-NC)
    Download as DOC, PDF, TXT or read online from Scribd

    Individual - Application - Rate Increase

    Uploaded by

    Ursula Johnson
    44 views2 pages
    Thank you for the information. I will keep your membership details confidential.

    Original Description:

    rate

    Original Title

    Individual_Application - Rate Increase

    Copyright

    © Attribution Non-Commercial (BY-NC)

    Available Formats

    DOC, PDF, TXT or read online from Scribd

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    Thank you for the information. I will keep your membership details confidential.

    Copyright:

    Attribution Non-Commercial (BY-NC)
    Download as DOC, PDF, TXT or read online from Scribd
    Download as doc, pdf, or txt
    44 views2 pages

    Individual - Application - Rate Increase

    Uploaded by

    Ursula Johnson
    Thank you for the information. I will keep your membership details confidential.

    Copyright:

    Attribution Non-Commercial (BY-NC)
    Download as DOC, PDF, TXT or read online from Scribd
    Download as doc, pdf, or txt
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    Return To:

    1100 Johnson Ferry Road


    Suite 300
    Atlanta, GA 30342
    Phone: (800) 950-7354
    FAX:
    404-252-0774
    Email: info@smrp.org
    Web: www.smrp.org

    INDIVIDUAL MEMBERSHIP
    APPLICATION

    Contact Information
    Name:
    ________________________________________
    Credentials (e.g.
    PE):_____________________________
    Company:
    _____________________________________
    Title:
    _________________________________________
    Address:
    ______________________________________
    Address:
    ______________________________________
    City, State Zip:
    _________________________________
    Country:
    ______________________________________
    Foundation Contribution of

    _________* (Optional)

    Select Chapters/SIGs (additional dues may apply)

    California: $25
    Carolinas: $0
    Central Ohio: $24 Chicagoland: $0
    Detroit-Windsor: $25 East Tennessee: $25
    Hamilton, ON: $0 Houston: $0
    Indiana: $25
    Middle TN: $0
    Mid-Ohio Valley: $0
    Nebraska-Iowa: $0
    NE Florida: $0
    North Texas: $0
    Northern Ohio: $25 Pacific NW $25
    SE Virginia: $0
    Pharma and Biotech SIG: $15
    Georgia: $25
    Oil, Gas,
    Petrochemical SIG: $15
    Reliability Analytics SIG:
    $15

    Select Membership Level


    $155 One-Year Membership
    $310 Three-Year Membership
    $25 Emerging Professional (Student)

    PAYMENT INFORMATION
    Total Amount Paid __________________________
    address below.

    Please mail all check payments to the

    Payment Method (CIRCLE ONE)

    Make all checks payable to:

    VS

    DC

    MC

    AX

    PO#_______

    Society for Maintenance and Reliability Professionals

    Credit Card #: _______________________________

    P.O. Box 116680

    Exp. Date: ________ Total Amount: _________________

    Atlanta, GA 30368 - 6680

    Name on Card: ______________________________


    Signature: __________________________________
    SMRP membership dues are not deductable as a charitable contribution, but may be deductible as an ordinary and necessary business expense. Please
    consult your tax advisor for more information. Foundation contributions are tax deductable as a charitable contribution.

    Getting to Know You


    Thank you for joining SMRP in order to better serve you, SMRP strives to keep accurate
    records about our overall membership demographics and about you in particular.
    Answering the following questions will help us to better customize our services and
    responses to your requests and needs.
    Please indicate (one) the industry you are working most
    closely with.

    Manufacturing Industries:
    Apparel (and other finished products made from
    fabrics)
    Chemicals/ oils/ energy
    Computer equipment
    Electronics/ instruments
    Fabricated metal products
    Food & kindred products
    Furniture & fixtures
    Industrial & commercial machinery
    Leather & leather products
    Lumber& wood products
    Machinery/ electrical
    Measuring, analyzing & controlling instruments
    Pharmaceuticals
    Primary metals
    Printing, publishing & allied industries
    Pulp & paper
    Rubber & miscellaneous plastic products
    Stone, clay, glass & concrete
    Textile mill products
    Tobacco products
    Transportation
    Other _________________________________
    Non-Manufacturing Industries:
    Commercial facilities
    Hospitals
    Mining
    Utilities
    Other _________________________________
    Government/ Academic/ Military/ Consulting:
    College or University
    Consulting
    Government Agency
    Military (specify branch)
    Research
    Other _________________________________

    What is your role in your organization?

    Craftsperson/Technician
    M&R Engineer Professional
    Other Engineering Professional
    Management
    Consultant
    Educator/Trainer
    Other_________________________________

    What is your gender?

    Male

    Female

    What is your birthdate?

    ____________________________
    How many years have you been in maintenance and reliability?

    Less than 5
    6-10
    11-15
    16-20
    More than 20

    Why did you join SMRP?

    Annual conference
    Benchmarking
    Case studies
    Chapter
    meetings
    Executive member meetings
    Networking
    Publications
    Speakers
    bureau
    If you were referred by a colleague, who referred you?

    __________________________________________
    ____

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