Online Membership Application

Please fill out the information below. Please take care to review before hitting the “Send” button at the bottom. The information will be forwarded to our Membership Committee for review and approval by our Board of Trustees. You will be notified of the status of your application. Do not make any dues payments until you have received notification that your membership has been approved. Thank you.

Required Field

Name

First Name

Last Name

Address

Address 1

Address 2

City

State/Province

Zip/Postal Code

Country

Cell Phone

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Home Telephone

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Business Telephone

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Occupation

Industry

Explain you Chian Descent

Village(s) you are associated with

Spouse

First Name

Last Name

Children (ages)

Recommended by

First Name

Last Name

Recommended by Telephone Number

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Online Membership Application

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The Panchiaki Korais Society, Inc.