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					       INVOICE and RENEWAL FORM– 2011 DUES
                                         Amount Due by January 31, 2011
Indicate payment method:
__ Check is enclosed payable to “BCAC”
__ We will use ACH payments (contact Kenneth A. Innocenzi at 203-287-1473; kinnocenzi@quinnipiacbank.com)

Indicate payment amount:
__ New Membership: $50.00
__ Renew Membership: $50.00
__ Member “In Transition”: $20.00
__ Member from a De Novo Institution: $25.00 (pay this rate through the second year of operation)

Please forward check with your completed Membership Form below to BCAC Membership VP for 2011:
                                                 Thecla Kirby
                                           Naugatuck Savings Bank
                                            1430 New Haven Road
                                            Naugatuck, CT 06770
                     2011 MEMBERSHIP FORM – New or Renewal (ONE FORM PER PERSON)
NAME
TITLE
INSTITUTION/FIRM/AGENCY
MAILING ADDRESS
(CITY/STATE/ZIP)
PHONE
FAX
EMAIL ADDRESS (permission to email
BCAC information to me; electronic delivery is our
only method)
SEMINAR TOPICS I WOULD LIKE TO
HEAR IN 2011:

				
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posted:11/23/2011
language:English
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