Date:

YEAR 2002

FORAGERS COSMETIC INDUSTRY ASSOCIATES MEMBERSHIP APPLICATION

New Member ; Present Member

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BUSINESS CONTACT INFORMATION

Salutation (Circle One): Ms. Miss Mrs. Mr.

First Name:

Middle Name/Initial:

Last Name:

Position/ Title:

Company/ Organization:

Business Address:

City:

State:

Zip Code:

Business Telephone:

Business Fax:

Business E-mail Address:

How many years cosmetic related industry experience:

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HOME CONTACT INFORMATION

Address:

City:

State:

Zip Code:

Home Telephone: (     )

Home E-mail Address:

Payment:
$125 - 1 Year Fee ; $200 - 2 Year Fee

Check ; American Express

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Please make check payable to:

FORAGERS COSMETIC INDUSTRY ASSOCIATES
135 East 55th Street, 4th Floor
New York, NY 10022
Phone: (212) 759-1991; Fax: (212) 755-4841

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Payment with American Express Card:

Card Number:

Signature

Amount

Exp. Date