ACM Chapter Label Request Form

Submitted By:
________________________________________

Address:
________________________________________

________________________________________

________________________________________

________________________________________

Email address:
________________________________________

Phone:
________________________________________

Fax:
________________________________________

Date:
________________________________________

Purpose:
________________________________________

________________________________________

Special Instructions:
________________________________________

________________________________________

Type of Media:


Mailing Labels:

__Cheshire
__Pressure Sensitive
__3 1/2 Diskette (ASCII)


Include on Label:
__Member number
__Member classification

Member Classification (Active only):
__Voting Members
__Associate Members
__Student Members
__Special Interest Group Members
  SIG__________

Zip Code Range/Market Location
From_________________
To____________________


___Request for a one-time listserv for email addresses only:
(This can not be combined with mailing addresses)


Return to:
Fran Sinhart, Coordinator
ACM Local Activities
1515 Broadway
New York, NY 10036
Fax: 212-944-1318
chapters@acm.org -- feel free to send your completed form as an attachment.