Membership Application - New

WiFT Louisiana New Member Application Form

Must be completed by all new potential members

First name

Last name

Phone

Multi-line address

Country/Region

Address

City

Zip / Postal code

Current Job Title

Company name

Primary Field of work (list up to 3)

Website or Linkedin profile link:

IMDb Profile link:

Product

Professional ($95 / 50% = $47.50)$47.50

Associate/Student ($50/ 50% = $25)$25

Patron ($100 / 50% = $50)$50

Dual Membership - ( $75 / 50% = $37.50)$37.50

Corporate ($500 / 50% = $250)$250

Why do you want to join Women in Film & Louisiana?

How can you help or volunteer with our group?

How did you hear about us?

Payment method: Indicate whether paying with Credit card /Paypal

Signature

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Date: