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SMPE ROSTER UPDATE FORM |
| Title (e.g., Mr, Mrs): |
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First Name: |
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Middle Initial: |
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Last Name: |
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Date of Birth: |
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Class of Membership: |
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Home Address (Street,
Apt. No., etc): |
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City: |
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State: |
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Zip Code: |
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Phone No. (incl area code): |
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Fax No. (if applicable): |
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Cell No. (if applicable): |
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Email or Web Address: |
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Name of Company: |
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Nature of Business: |
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Position(GenMgr,PEngr,etc): |
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Office Address (Street,
Suite No., etc.): |
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City: |
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State: |
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Zip Code: |
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Phone No., (incl. AC & Ext.): |
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Fax No. (if applicable): |
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Cell No. (if applicable): |
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Email or Web Address: |
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Preferred Mailing Address
For Society Mailings
(Home or Office): |
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Receive Society Notices by
Email? (Yes or No): |
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Current Personal Information
(e.g. licenses in force, memberships in other prof. societies, papers
published): [Optional]
Wife’s name__________ |
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