Information about you…
Name_______________________________Company Name__________________________________
Company Address____________________________________________________________________
City/State/Zip________________________________________________________________________
Phone_(_______)_________________________Fax_(_________)_____________________________
Residence Address___________________________________________________________________
City/State/Zip________________________________________________________________________
Cell Phone(________)________________________Fax_(________)___________________________
I would like mail sent to my: Business Residence
E-mail______________________________________Web Site_______________________________
Local Chapter you are joining: Daytona Beach Area Chapter, Daytona Beach, FL
Board of REALTORS® in which you hold membership________________________________________
Type of membership held: REALTOR® REALTOR-ASSOCIATE® Affiliate
What year did you become active in real estate?_______
REALTOR® designations you have earned_________________________________________________
NRDS ID#__________________________________________________________________________
Were you a national WCR member in the past 12 months?____________________________________
Following question for National Affiliate applicants only—one of the above MUST be checked to become a National Affiliate WCR member.
Is your REALTOR® Board membership: Under your name? Your company name?
DUES AMOUNT OWED
National dues: 
$96.00
State dues: $34.00
Local dues: $25.00
TOTAL DUES: $155.00 ($9 of your dues is a one-year subscription to Connections)
METHOD OF DUES PAYMENT
Check for $__________ (payable to “WCR”) is enclosed.
Charge $ to my: Visa MasterCard American Express Diners Club Discover
Credit card #_________________________________________________Expiration_______________
Signature___________________________________________________________________________
