(check one:) __    Single Membership Fee: $30.00
                                   __ Household Membership Fee: $40.00

Name(s):___________________________________     __ New  __ Renewal  

Address:___________________________________     __ Check#______  __ Cash

City:___________________________ State:_______________ Zip:_____________

Home Phone:(_____)_____-_______  E-Mail Address:________________________

Nick Name (How do you want your name badge to read?):___________________

Would you like to join a Special Interest Group (SIG)?    ___Yes   ___No
What type of SIG would you be interested in? 
____ Photo SIG   _____ Other SIG: ______________________________________

What types of programs are you interested in?  Check all that apply, and
optionally indicate the software you use.

__ Spreadsheet:______________________________________       __ Hardware

__ Word Processing:__________________________________       __ Internet

__ Database:_________________________________________

__ Desktop Publishing:_______________________________       __ Beginner

__ Graphics:_________________________________________       __ Intermediate

__ Other:____________________________________________       __ Advanced

Do you have additional experience you'd like to share?

________________________________________________________________________

________________________________________________________________________

Would you be willing to be listed in the Help Line (newsletter & web page)?

If so, subject(s):______________________________________________________

Calling Hours:____________________________    Phone:(_____)_____-_______

Where did you learn about the Thousand Oaks Personal Computer Club?

__ Store     ___ Newspaper     ___ Person     ___ Other: _______________

Name of Store, Newspaper, Person, or Other: ____________________________