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Jennifer Forell
Membership Chair, DRG
Wacker Silicones
3301 Sutton Rd.
Adrian, MI 49221
Phone: 517-264-8208
Fax: 517-264-1174
jennifer.forell@wacker.com
MEMBERSHIP APPLICATION
Please print this form from your browser and send it to the address above with check or money order,
for twenty-five ($25.00) dollars for one year's paid MEMBERSHIP, to the Detroit Rubber Group.
(Corporate rate for all members of a single corporation is $200 annually. Contact Jennifer Forell for details.)
NAME______________________________________________________________________________
Company
Name______________________________________________________________________
Company Address ____________________________________________________________
City____________________________________State_________Zipcode_______
Company
Phone ___________________________ Ext __________ FAX ________________________
Your Title _______________________________________________________________
Home Address ___________________________________________________________
City____________________________________State_________Zipcode_______
Home Phone ____________________________ Fax ______________________________
Email Address ___________________________________________________________
Mailing Preference:
Home -----Business ------ACS Member ------Div Member
(___)--------(___)--------------(___)---------------(___)
Would you work on a Committee:
Education -------Scholarship -------Christmas Party-------- Golf Outing --------Membership
(___)-----------------(___)------------------(___)--------------------(___)--------------------(___)
DRG Membership Officer
Below - Membership Officer use only:
Date Paid: ___________ Check Number: ___________ New Member