Pacific Regional Chapter of the Society of Quality Assurance (PRCSQA) Membership Application Last Name: First Name: Title: Company: Address: City: Phone: Email: State: Fax: Zip: Membership Information: Are you a current member of SQA? If yes: Affiliate Active Yes No Membership Pending Year joined SQA: Areas of Interest (check all that apply): FDA GCP GLP GMP EPA FIFRA TSCA Other (please specify): Would you like to share your name and associated information with other PRCSQA Members? No If Yes – Please indicate which information you would like included: Title Company US Mail Address Phone Fax E-mail Please use this section to suggest future training ideas and topics for our group: Fees for 2015: $25 (Jan 2015-Dec 2015) METHOD OF PAYMENT: Enclosed is my check made payable to PRCSQA. Remittance must be made in US dollars. A surcharge may be assessed to cover any returned checks. Charge to the following credit card (circle one): MasterCard VISA AMEX Card Number: Expiration Date: Cardholder Signature: ________________________________________________ Cardholder Name as it Appears on Card: Credit Card Billing Address: Please include postal code. RETURN FORM AND PAYMENT TO: PRCSQA, 154 Hansen Road, Suite 201, Charlottesville, VA 22911 USA; Tel: 434.297.4772; Fax: 434.977.1856; E: [email protected] Yes
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