As an applicant for (member category) _______________
in the International Press Club of Chicago, I submit the following
information so that the Committee may consider my
qualifications and status. |
Name: |
(Optional) Spouse Card - spouse's name: |
Home street
address: Apt. # |
City:
State
Zip |
Home
phone:
Home
fax: |
E-mail address:
@ |
Employer (company name): |
Street address: |
City:
State
Zip |
Position: Phone:
Fax: |
To comply with the IPCC Constitution and By-Laws,
applicants must list names of employing news media with exact dates
(month & year) of past service in world or domestic working press: |
Employing
media
Position Service Dates
Location |
1. |
2. |
3. |
4. |
List two or more working press and their organizations, who
are personally familiar with your employment: |
1. |
2. |
|
The Admissions Committee welcomes any additional information which will assist it in evaluation of the
applicant's qualifications for membership. |
I authorize the Admissions Committee to make any relevant
inquiries with the facts set forth herein. |
Signature:
Date: |