PARENTS WITHOUT PARTNERS, INC.
Application for Member-At-Large

If you wish to apply for membership in Parents Without Partners, Inc. as a Member-At-Large, please print out this form, complete all the information requested, and mail it with a check, money order, or credit card number to the address below. You may fax it to 561-395-8557 if you prefer. If, upon review, it is determined that you reside in the service area of a local Parents Without Partners chapter, your application will be returned and you will be referred to the local chapter.

Ann Hanson
International VP of Membership
3802 Craig Drive
Flint, MI 48506

If you have question, telephone 810-231-9447 or FAX 561-395-8557 or Contact the Membership Chair.

1. Name __________________________________________________________
          First Name       Initial            Last Name 

2. Address _______________________________________________________
            Street Address                          Apartment #

3. City, State, Zip/Postal _______________________________________
                           City State Zip Code/Postal Code Country

4. Social Security/Social Insurance Number (optional) ____________


5. Drivers License Number ________________________________________

6. Phone Number _________________ E-mail address _________________

7. Sex:     Male        Female

8. Marital Status:  Divorced   Separated   Widowed   Never Married

9. Birth Date of Applicant (Month/Day/Year) ______________________

10. Number of Living Children ______________

11. Living Children's Birth Dates (youngest to oldest)
     Month/Day/Year _________________ Male Female
     Month/Day/Year _________________ Male Female
     Month/Day/Year _________________ Male Female
     Month/Day/Year _________________ Male Female
     Month/Day/Year _________________ Male Female


12. Have you ever been convicted of a felony?   Yes    No

13. Have you ever been denied or been expelled from membership in a
    PWP Chapter?    Yes    No

14. I provide the following professional reference for verification 
    of my eligibility for membership in Parents Without Partners, 
    Inc.

Name ______________________________________ Title ________________

Company Name _____________________________________________________

Address __________________________________________________________

City, State, Zip/Postal __________________________________________
                        City State Zip Code/Postal Code Country

15. Credit Card Data: I authorize payment of $40.00 US funds for my 
    dues in Parents Without Partners, Inc. to be charged to my: 
     
    Visa        Mastercard            American Express

    Credit Card Number _________________________ Exp. Date _______

 Signature on Card _______________________________________________

 I hereby apply for membership in Parents Without Partners, Inc. 
 and enclose payment of $40.00 (US dues for one year. I understand 
 that my Member-At-Large status will entitle me to membership in 
 Parents Without Partners, including all benefits, with the 
 exception of voting rights and privilege of holding office at any 
 level.
 I affirm that I am a single parent and that the information on this
 application is true and correct.
 I understand that if my eligibility changes, I will relinquish my 
 membership card immediately to Parents Without Partners Inc.
 I pledge adherence to the aims and purposes of Parents Without 
 Partners, and agree to be bound by and abide by its Constitution, 
 Bylaws, rules and  regulations.
 I understand that my membership card is not transferable to any 
 other person, under penalty of forfeiture of my card and membership, 
 and this card remains the property of Parents Without Partners, Inc.
 I authorize officials of Parents Without Partners, Inc. to make 
 inquiries as to my eligibility.
 I understand that if I falsify any information on my application, 
 this may be grounds for immediate revocation of membership.

16. Applicant's Signature ________________________________________


                     Date ________________

FOR OFFICE USE ONLY:

As an official of Parents Without Partners, Inc. I have accepted 
this application and verify that a professional verification letter 
is on file for this applicant.

Signature ____________________________________________ Date______