Membership Application - fax to 724.694.0570

Primary Applicant:
Last Name:	First Name, M.I.:
Social Security #:	Birthdate:
Residence Address 1: (not P.O. Box)
Residence Address 2: (not P.O. Box)
City:	State, ZIP:
Mailing Address 1: (if different)
Mailing Address 2: (if different)
City:	State, ZIP:
Home Phone:	E-Mail Address:
Drivers License #:	Drivers License State:
Position:
Employer:	Work Phone:
Under penalties of perjury, I certify that: (1) The number shown on this form is my correct taxpayer identifications number, (2) I am not subject to backup withholding because (a) I am exempt from backup withholding, or (b) I have not been notified by the Internal Revenue Service (IRS) that I am subject to backup withholding as a result of a failure to report all interest or dividends, or (c) the IRS has notified me that I am no longer subject to backup withholding, and (3) I am a U.S. Person (including a U.S. Resident Alien). Certification Instructions. Cross out item 2 above if you have been notified by the IRS that you are currently subject to backup withholding because you have failed to report all interest and dividends on your tax return. Cross out item 3 and complete a W-8 BEN if you are not a U.S. person.
Employer's Address 1:
Employer's Address 2:
City:	State, ZIP:
Mother's Maiden Name:
The Internal Revenue Service does not require your consent to any provision of this contract other than the certifications required to avoid backup withholding.
Signature: