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. 102nd Ave., Westminster, CO 80021