Full Name (First Name, Middle Initial, Last Name):

Position Title:

Professional Designation:/Certification
(i.e. CCP, PHR, SPHR, CEBS, etc.)

Company Name:

Company Mailing Address: (street)

(city, state, zip:)

Phone Number:

Fax Number:

Email Address:

RCA Member Referral - Please list Sponsor name:

What HR disciplines do you work in? (check all that apply)

Compensation   Recruitment
Benefits   Training
HR Information Systems   Employee Relations
Other

How many years of HR experience do you have?

Less than 1 yr. 1-3 yrs 4-6 yrs
7-9 yrs 10+ yrs

What is your classification type?

Entry-level Management
Professional Executive

ANNUAL MEMBERSHIP DUES : $55.00

Check - payable to Richmond Compensation Association

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Mail Payment To:
Richmond Compensation Association
Attn: Kathy K. Lauver
Richmond Compensation Association
P.O. Box 5931
Midlothian, VA 23112

Card Holder Name (as it appears on card):

Card Number:

Expiration Date:

Authorized Amount:

Card Holder's Address: (street)

(city, state, zip)

Card Holder's Signature:

Date:

Please indicate if you would like a receipt mailed to you:

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Taxpayer Identification Number: 54-1450304