Membership Application Form
Basic Information
First Name:_________________     Last Name:_________________	Male:___  Female:___
Email (Please print clearly):__________________________________________
Daytime Phone:_________________	Evening Phone:_________________
Mobile Phone:_________________	Fax:_________________
Home Information
Address:_________________________________________________________________________
City:_______________________         State:______	Zip:______
Career and Company Information
Company:______________________________________________	Occupation:________________________________
Title:________________________________________________	Department:________________________________
Self Employed?    Yes:___  No:___
Job Description:_________________________________________________________________________
Address:_________________________________________________________________________
City:_______________________         State:______	Zip:______
Would you like to be in the FSIX Directory?
Yes:___  No:___
Which information can we include in the Directory?
All: ___     Basic(Name, Phone, Email): ___     Home + Basic: ___     Business + Basic: ___
Would you like to help out FSIX?
Yes__ No __
Annual Membership Fee $45 - Please make checks payable to FSIX. Send to: PO Box 4139, Grand Central Station, New York, NY 10163 www.f-six.org   212-459-4956   info@f-six.org
I agree to adhere to FSIX’s policy on confidentiality, which forbids the disclosure of any membership information, including the contents of the Membership Directory, to any individual or organization without the consent of the FSIX member concerned. I understand that the use of directory information is strictly for networking and socializing purposes. Direct sales, marketing, and/or fundraising must be approved by the Board of Directors of FSIX. I also understand that my failure to comply with this policy may result in the suspension of my membership privileges.
Signature ________________________________	Date _________________
How did you hear about us?