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THE QUARTER-CENTURY SOCIETY, INC.

APPLICATION FOR MEMBERSHIP

Please Type or Print All Information in Ink 

 

Name of Applicant

First

Middle

Last

 

 

Hourly c

Salaried c

 

Address

Number and Street

Apt. No.

 City/Town

State 

Zip 

 

 

    
                EMail Address

 

 PhoneAlternate  Phone 

 

 

 

Month/Day/Year

Chapter Name

Date of Birth

 

Date of Original Hire

Date Eligible for Membership

 

I hereby apply for membership in The Quarter-Century Society, Inc., having satisfied the eligibility requirement stated in its constitution as indicated by my record of service below.

                                                          _____________________________  _________

                                                          Signature of Applicant                   Date

 

Record of Service (with International Paper or Qualified Subsidiary or Affiliate)

 

Name of Business Unit, Group or Division

Location

Dates of Employment

Length of Service

From

To

Years

Months

Days

 

 

 

 

       
       
       
       
       
       

 

 

_______________________________

Supervisor, Employee Relations Manager

or Personnel Representative

_____________________________

Secretary, The Quarter-Century Society, Inc.