Silicon Web Costumers Guild (SiW)
Membership Form

_______ Individual or Head of Household Membership for $14/year

_______ Additional Household Membership for $6/year
For multiple people at the same physical address.

_______ Non-Primary Chapter Membership for $6/year
For people who belong to multiple ICG chapters.

Amount Enclosed

Member Information:
Name ______________________________________________________

Address ______________________________________________________

City ___________________

State ____

Postal Code ____________

Country _____________________________

Phone ______________________________________________________

Email ______________________________________________________

Web Site ______________________________________________________

Send checks or money orders made out to:
Silicon Web Costumers Guild, Bruce R. MacDermott

and this printed completed form to:
Bruce R. MacDermott
2801 Ashby Avenue
Berkeley, CA 94705

Please include your correct mailing address if it is different from your imprinted check address.