General Membership Registration
  Register by filling out the form below and reading and agreeing to the WISE membership agreement on the page that follows:
Registration Form:
(Please fill in all the fields below so we can best service you.)
* Membership Status:
* First Name:
* Last Name:
* Company Name:
Home Contact Information:
* Home Street Address #1:
Home Street Address #2:
* City:
* State/Province: * Zip/Postal Code
* Country
Home Phone: Home Fax:
* E-mail: Personal website:
Is your business contact information the same as your home contact information?  
(If yes it is not necessary to fill out the company contact information fields below.)
Business Contact Information:
* Company Street Address #1:
Company Street Address #2:
* City:
* State/Province: * Zip/Postal Code
* Country
Work Phone: Work Fax:
Work e-mail: Company website:
Additional address options for your convenience:
I have a separate shipping address.
I have a separate billing address.
* I would like my benefits in:
* Please send correspondence from WISE to:
WISE Membership Directory Listing Information:
* Would you like to be listed in the WISE Membership Directory?  
Payment Method:
* Please choose which payment plan you wish:
  Annual Fee: US$500.00 (paid in full)
  $150.00 + Monthly Payment Plan: US$50.00 over 9 months. Total of US$600.00
* Credit Card:
* Credit Card Number:
* Exp. Date  / 
Total Billed to Credit Card:
In order to supply you with further information (local WISE membership events, meetings, and promotional offerings) and for you to receive area membership benefits, we may relay your name and address to a WISE continental office. If you have any objection to this, please check this box.
  I do not wish my contact information to be relayed to other WISE offices
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