Name: ____________________________________ Date______________________________

Company: _________________________________ Birthday (Month & Day Only)_________

Established Date: ___________________________

Address: __________________________________

__________________________________ Referred by: _____________________

__________________________________

Phone: ___________________ Fax: __________________ Cell Phone: _________________

E-Mail: ____________________________ Web Address: _______________________________________

Membership of Other Organizations:_________________________________________________________

Degrees or Formal Training:_____________________________________________________________

Describe your Professional Videography Experience/Specialty:_____________________________________________________________

_______________________________________________________________________________

______________________________________________________________________________________________________________________________________________________________

What do you want to get out of CoPVA? ______________________________________________________________________________________________________________________________________________________________

Is there a committee would you like to serve on?_______________________________________________

I agree to abide by the By-Laws of this Association and will pay the necessary dues and attend meetings.

Signature: ________________________________ Date: ________________________

-----------------------------DO NOT WRITE-BOARD REVIEW ONLY--------------------------

Membership Status: ________________ Date Approved: ________________________

Send to: Maureen Bacon - 11545 W. 102^nd Ave., Westminster, CO 80021