Form

SHASTA PROFESSIONAL ASSOCIATION

Membership Application

Date of Application:*

/ Month / Day Year

Sponsoring Member:

Please leave blank if you need a member assigned to you.

PERSONAL INFORMATION

Full Name

Years in Shasta Co.

Spouse Name

Spouse Occupation

Children's Names

Home Address

Home Phone

BUSINESS INFORMATION

Business Name

Your Job Title/Position

Business Address

Business Phone

Type of Business

Years in Operation

E-mail Address

If your business' website address is not your email address domain, please specify the website address here:

BUSINESS REFERENCES

Name and Business

Years Known

Name and Business

Years Known

COMMUNITY INVOLVEMENT

Please describe your involvement in our local community:

GENERAL INFORMATION

What do you bring to S.P.A. as a potential member?

How can S.P.A. help you and your business succeed?

Additional Questions, Comments, and Suggestions

Who will pay the dues?

Individual Business