Company Name: _________________Business/Industry Sector: ______
Attention: ________________________Title: ____________________
Address: ________________________City: _____________Zip: _____
Phone: _____________________ Fax: __________________________
E-mail: ___________________________________________________
I am joining on behalf of my company
I am joining as an individual
Checks should be made payable to: CSUCI Foundation – B&TP
All dues cover incidental but necessary costs such as printing, mailing, faxes, etc. directly
related to B&TP meetings.
Annual dues per year on anniversary date: $100
Signature: _______________________________________________________________
Check Enclosed $ ______________
Visa________ Mastercard________
Credit Card #_____________________________ Exp. Date_______________________
Name of contact person representing our company who will receive correspondence,
publications, invitations, etc., if other than above:
________________________________________________________________________
I would like to be a part of the following Sector Committee:
Applied Mathematics, Computer Science & Engineering
Science and Technology
___I am interested in learning more about your Student Intern Program.
___I am interested in learning more about scholarships.
___I am interested in other (please specify interest)
(Please mail or email this form to the address listed above.)
Thank you for your interest and investing in our future!
APPLICATION FOR MEMBERSHIP
Business & Technology Partnership
California State University Channel Islands
One University Drive
University Advancement
Camarillo, CA 93012
PHONE (805) 437-8919 FAX (805) 437-2715
