Offline Registration Form: VSBN Membership

VSBN Membership Registration

Support VSBN's mission of promoting environmentally sound building practices and sustainable development for Virginia by becoming a member or renewing your membership for the Year 2012.

Use this form for mail registration or to pay by check. To register online through our secure server, please use our online form.

First Name	Required
Last Name	Required
Title
Organization/Business	Required
Address (line 1)	Required
Address (line 2)
City	Required
State	Required
ZIP Code (ZIP + 4)	Required
Country	Required
Email	Required
Phone	Required
Fax
Website
Please check box if this is a renewal	Yes, this is a renewal
VSBN Online Member Directory	Do not list my name on the VSBN Members page.
NEW! Capital Bikeshare Membership	Send me 2 Capitol Bikeshare free 24-hour memberships (available through Dec. 2012) Send me 4 Capitol Bikeshare free 24-hour memberships (available through Dec. 2012)

Please check all categories that best describe you and your company.
Architect Engineer Builder College K-12 School Consultant Developer
Energy Federal Gov. State Gov. Local Gov. Non Profit Org Waste Financial
Other

Membership Type	Annual Fee
Individual	$50
Non-profit and Government	$75
Small Business (Revenues under $500,000)	$125
Medium Business (Revenues between $500,000 - $5 million)	$325
Large Business (Revenues over $5 million)	$675
NEW! 25% discount when you enter your organization in the SMART Building Directory.	$74
Additional Donation	$10 $25 $50 $100 $500 $1000

Your total is:

PAYMENT OPTIONS

Please complete all payment information below. Check Here if billing address is same as registration

First Name	Required
Last Name	Required
Organization/Company
Billing Address	Required
Billing City	Required
Billing State	Required
Billing ZIP Code	Required
Billing Country	Required
Billing Email	Required
Billing Phone	Required
Card Type/Number	Required
Expiration Date	Required
3-Digit Card Verification Number	Required What's This?

Select the Print button below to print a copy for your records, or to print and mail your registration form. If you register by mail and would like confirmation that your registration has been processed, please provide an email address.

If registering by mail, please print and complete this form, make checks payable to Virginia Sustainable Building Network, and send with your payment to:

     Virginia Sustainable Building Network
     Membership Form
     P.O. Box 6539
     Arlington, VA 22206

     Tel: (703) 486-2966

FOR OFFICE USE ONLY:
Rec'd _____________________	Ck# _______________	DataX _______________	DataACT _______________	TYL _______________	WS _______________
Note:					JAN12