The West Point Society of Philadelphia

ANNUAL DIRECTORY AND REGISTRATION FORM

1 SEPTEMBER 2009 – 31 AUGUST 2010
Please use this form to remit your annual dues and bring current your information for publication in the Society’s
Membership Directory. Unless indicated to the contrary in the space provided below, you hereby consent to the listing of
your current information in the Society’s Membership Directory. Send your dues, MADE PAYABLE TO “THE WEST
POINT SOCIETY OF PHILADELPHIA,” and completed application to:

West Point Society of Philadelphia

c/o Bill Belknap ‘81
845 Tremont Drive
Downingtown, PA 19335

THE WEST POINT SOCIETY IS A “NOT FOR PROFIT ORGANIZATION” FORMED UNDER SECTION 501(C)(3) OF
THE INTERNAL REVENUE CODE.
MEMBERSHIP REGULAR $40.00 CURRENT STATUS: ACTIVE DUTY
: SUSTAINING $50.00 RESERVES
BRIGADIER $75.00 RETIRED
FIVE STAR $150.00 CIVILIAN
CORPORATE $500.00 RESIGNED
LIFE $500.00 Check
one
PLEASE COMPLETE THIS SECTION:

LAST NAME: _____________________ FIRST NAME: _____________ M.I.: __________, Rank__________

USMA CLASS:________; USNA Class__________, USAF Class_________; Other_________; Assoc. Mem___
CHECK HERE IF NO CHANGES FROM LAST DIRECTORY:
HOME ADDRESS: ______________________________________________________________________
CITY: __________________________ STATE: ______ ZIP: ________-_______
HOME PHONE: ( ) _____________ CELL PHONE ( ) _____________, FAX ( )_________________
SPOUSE’S FIRST NAME: _____________________E-MAIL ADDRESS: _____________________________

CURRENT OCCUPATION:
BUSINESS TITLE: _______________________ COMPANY NAME: _____________________________________
BUSINESS ADDRESS: ________________________________________________________________________
CITY: __________________________ STATE: ______ ZIP: ________-_______
BUSINESS PHONE: ( ) ________________ EXT.: _______ FAX NO.: ( ) ____________________
BUSINESS E-MAIL ADDRESS: ____________________________________________________________
TYPE OF BUSINESS: _______________________
I am willing to assist the Society with the following activities (CIRCLE ONE OR MORE):
Founders’ Day Dinner Membership Career Advisory Networking Membership
Committee Directory
Assembly Articles Advertising Programs Newsletter Luncheon
Speakers
CHECK HERE IF DO NOT CONSENT TO YOUR INFORMATON BEING LISTED IN THE DIRECTORY:

SIGNATURE: ________________________________________ DATE: ____________________________

NOTE: AN ASSOCIATE MEMBER’S INITIAL MEMBERSHIP APPLICATION REQUIRES THE ENDORSEMENT OF
TWO USMA ALUMNI MEMBERS IN GOOD STANDING.
_________________________________________ ____________________________________

ONLY MEMBERS WHO HAVE PAID HIS/HER DUES AND ARE OTHERWISE MEMBERS IN GOOD STANDING ARE
ENTITLED TO RECEIVE A COPY OF THE SOCIETY’S DIRECTORY.

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