Membership Form Membership Form Gender: o M o F Membership Type: o Representative o Individual o Student ext * Full Name: Please list below the names according to how you wish to be called, and listed on your name badge. Your name badge will include your Title (if listed), First Name, Last Name, Position and Organization. (3 lines of no more than 27 characters per line.) (Title: Rev., Rabbi, Dr., etc.) First Name, Last (Family) NameParagraph Position: Organization: Mailing Address: o Home o Office (Please check if home or office address) Street Address or P.O. Box City * State Zip Code Phone Email Please explain how you would like to support the activities of the Roundtable: e.g., Interfaith month committee, event organization, service projects, and/or newsletter articles. Paypal payments can be made by going to URL https://www.paypal.com/donate/?hosted_button_id=ZSW4YC3R8AZG4 AMOUNT Paid:_______________ Fee paid by: o Cash o PayPal o Check #_________________ * Students state name of school Signature: * Payment Date [mm/dd/year] * Submit If you are human, leave this field blank.
