2018 CIPC 2018-CIPC Conference Information Packet | Page 20

Membership Payment Form - Part I Please check all that apply: Corporate Membership - $5,000 Retail Agency Membership - $500 Individual Membership - $295 Grand Total Due $ _________________________ Please make checks payable to MarketScout. I hereby agree to apply for the above 2018 CIPC Membership. Company Name: _______________________________________________________________________ Contact Name: _____________________________Title/Position: ________________________________ Mailing Address: _______________________________________________________________________ City: ____________________________________ State: _____________________ Zip: ______________ Phone: ______________________________________ Fax: ____________________________________ E-mail: _______________________________________ Website URL: ___________________________ (MEMBERSHIP PAYMENT FORM - PART I) Tel: [phone] Email: [email protected] www.privateclientcouncil.com