| Last Name:_______________________________________________________________ |
| First Name:_______________________________________________________________ |
| Title:____________________________________________________________________ |
| Company:________________________________________________________________ |
| Address:_________________________________________________________________ |
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________________________________________________________________________
(City, State and Zip Code) |
| Phone:____________________________FAX:_____________________________ |
| Email:__________________________________________ |
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Membership Information:
Are you a current member of SQA?_______Yes _______No If yes:_______Affiliate _______Active _______Membership Pending Year Joined SQA:_________ Are you a current member of PRCSQA? _______Yes _______No Year joined PRCSQA:_______ |
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Areas of Interest (check all that apply):
FDA______ GCP______ GLP______ GMP______ EPA______ FIFRA______ TSCA_______ Other (please specify):__________________________________________ |
| Please print out this form. When completed, please submit this form with the appropriate fee to: PRCSQA
|
Membership Fees for Calendar Year 2003 (circle one)
Nonmember of SQA - $20.00 SQA Member - $20.00 Student - $10.00 Newsletter Only - $10.00 Make checks payable to: PRCSQA |
| Please use this space to suggest future training ideas and topics for our group:
_______________________________________________________________________________________ _______________________________________________________________________________________ _______________________________________________________________________________________ _______________________________________________________________________________________ |
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