the Association of Building and Zoning Code Enforcement Officers in and near Chautauqua County, New York
2008 APPLICATION FOR MEMBERSHIP
WESTERN SOUTHERN TIER BUILDING OFFICIALS
Please fill out completely listing all work places and contact information, type or print after copying and pasting this section to your word processor.
NAME__________________________HOME PHONE_______________________
MAILING ADDRESS__________________________________________________
CITY_____________________________STATE_______________ZIP__________
COUNTY__________________ NYS CERT #_________________ FDID________
WORK PHONE(S)__________________________ FAX______________________
E-MAIL ADDRESS (indicate accurately, i.e. upper/lower case, all dots)
__________________________________
MUNICIPALTY / BUSINESS NAME(S)____________________________________
____________________________________________________________________
POSTION OR TITLE__________________________________________________
DEDUCT $15.00 if you are a member of another NYSBOC Chapter such as Niagara Frontier or
____ $40.00 Active Member Any individual currently certified as a
____$45.00 Associate Member Any individual not certified as a NYS code enforcement official or employed as a code enforcement official.
____No Fee Honorary Member Conferred by the membership of the organization.
Amount enclosed:___________
APPLICANT SIGNATURE______________________________DATE__________
Please return this form with check or voucher to:
Western Southern
Allan L. Zurawski, Treasurer
City of
342 Central Avenue
Dunkirk,
Office use only:
Payment Received Amount $ Date: / / Check No. Cash______
Voucher ________________________ Date __/ ___/___ _______Voucher returned ___/_ __/__ __________