| Name____________________ | Employer/Organization address______________ |
| Title_____________________ | _______________________________________ |
| Home address_____________ | Your area(s) of work interest________________ |
| ________________________ | _______________________________________ |
| Your mailing address_______ | List special interest area(s)__________________ |
| ________________________ | County # or agency_______________________ |
| Work phone______________ | Ext.________ |
| Membership | Membership Category | Employer Type |
| __New (never a member) | __Regular.......... ..$25.00 | __County |
| __Continuing (member last year) | __Student............ $12.50 | __State |
| __Renewal (previous member) | __Contributing......$35.00+ | __ Students |
| __Private Agency |
| Association | Employee Job Function |
| __1. Northland | __Mgmt./Supervisor |
| __2. S. Central | __Social Worker |
| __3. Eastern | __SS Para Prof. |
| __4. W. Central | __Economic Support Spec. |
| __5. S. Eastern | __Clerical |
| __6. N. Central | __Employment Program |
| __Other |
| Sherri Arnold |
| Kenosha Co. - Goodwill |
| 8600 Sheridan Road |
| Kenosha, WI 53143 |