A-DC Membership Form

Member Record Maintenance

The membership list is strictly confidential, and will not be disclosed to anyone or any agency
outside the A-DC Membership Committee without your prior notification and consent.
It will only be used for member benefits, verification (if desired),.and your membership card.

Prefix:

First Name: *

Last Name: *

Phone Number: *

E-mail Address: *

Street Address:

Address Line 2:

City:

State:

Postal Code: *

Country: *

Gender: *

Female
Male

Age: (approximate)

Occupation

Area of interest

Representative(s) To Visit

* Required Create Email Forms

I hereby submit my above information
for membership in A-DC

You may place A-DC logo on your web site upon Membership approval.

1629 K Street, NW Suite 325, Washington, DC 20006 202-221-5022 Fax 202-318-2503 info@A-DC.org

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(OFFICE USE ONLY)

Approved _____ Disapproved _____ Date ____________ Reviewed By: ______________

Comments: ________________________________________________________

__________________________________________________________________

A-DC Membership Form

Member Record Maintenance

I hereby submit my above information for membership in A-DC

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I hereby submit my above information
for membership in A-DC