Member-At-Large Application

Parents Without Partners, Inc.
Membership Application

To apply for PWP membership, simply fill out the form below, include your credit card data and click on the "SUBMIT BUTTON" at the bottom of the page. You will then receive an email confirmation and form. If you prefer not to submit credit card data, you can use this MEMBER-AT-LARGE FAX FORM. Simply print out the form, fill it out the required information, and fax it back to Parents Without Partners at (312) 321-6869.

PAYMENT INFORMATION: 
Credit Card:   Visa  Mastercard  American Express
Credit Card Number 
Expiration date (eg 03/97)
PERSONAL DATA: 
Name:     First  
         Middle   
           Last 
Daytime Phone:    
Evening Phone:  
        email:  

       Street:  
      Street2:  
         City:   
        State:  
          ZIP:
Are you? Female or Male

What is your marital status?

Birthdate of Applicant:
(e.g.  June 4, 1960 would be typed 06/04/60) 

Number of Living Children:  

Living Children (youngest to oldest):

Sex:  
Birthdate: 

Sex:  
Birthdate: 

Sex:  
Birthdate: 

Sex:  
Birthdate:
Have you ever been convicted of a crime other than a traffic violation? Yes or No

Have you ever been denied or expelled from membership in a PWP chapter? Yes or No 

Please provide the following professional reference for verification of eligibility to be a member of PWP:

          Name:  
    Profession:  
         Phone:    
        Street:  
       Street2:  
          City:   
State/Province:  
      Zip Code:

By checking this box you give PWP International permission to contact the above person to verify your single status.

ACKNOWLEDGEMENTS:

  • Along with dues payment, I hereby apply as a member at large with Parents Without Partners, Inc. for one year.
  • I understand that my dues qualify me as a member of PWP, receiving all benefits except voting rights and can not hold an 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 International.
  • 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 PWP, 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 expulsion.

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The PWP International office can be reached at (312) 644-6610