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| Philippines Incorporation 1974 — APS Affiliate #54 MEMBERSHIP APPLICATION FORM
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(1) All entries are REQUIRED except those in yellow text and you will be notified if you omit one (click X to get back into form)
For questions or inquirers contact:
IPPS Coordinator Overseas Operations and Acting Secretary/Treasurer
(2) After you SUBMIT this form, you will receive a confirmation email and be moved to the membership page.
Online payment can be made here if desired.
(3) You may TAB through the form but clicking ENTER is the same as clicking the SUBMIT button
(4) Clicking the RESET button will remove all entries and you will have to start again
(5) Clicking the PRINT button will print all the information within the YELLOW rectangle
James R. Larot Jr.
4990 Bayleaf Ct.
Martinez, CA 94553
Tel: 925-229-1043
Email: jimbert_larot@yahoo.com
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