First Name:

Last Name:

Please make sure you use the same name that is on file with RWA_® National.  We are required to validate our membership roster with them on a yearly basis.

Street Address:

City:

State/Province:

Zip/Postal Code:

Country:

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Telephone:

Email:

Secondary Email:

RWA_® Number:

   or      

  I have just applied for RWA membership and will provide my number within 3 months of this application or I will be suspended from the chapter and forfeit my membership fees.

Pseudonyms:

New chapter membership dues are $25 USD.

Payment Method:

Check or Money Order             PayPal

Are you published? (Check all that apply)

Published Credits and Comments:

May we publish your name on our website?

   Yes           No      Please publish my pseudonym instead

Are you RWA PRO recognized?    Yes   
Are you RWA PAN recognized?    Yes