Virginia Professional Electronics Association
Application for Membership
 Please complete all required fields (*)
 Section One: Applicant Information
 First Name *
 Last Name *
 Email Address *
 Verify Email Address *
 Street Address *
 City *
 State *
 Zip Code *
 Home Phone
 Cell Phone
 Fax Phone
 Section Two: Business Information
 Name
 Owner/Institution Name
 Website URL
 Phone *
 Section Three: Membership Information
 Membership Type *
 Membership Class *
 NESDA Member?
 Subscribe to VPEA Newsletter?
 Section Four: Referral Information
 VPEA Member's Name
 VPEA Member's Company
 Company Representative to VPEA
 Section Five: VPEA Product Survey
(Check all that Apply)

Appliances (Large)
Appliances (Small)
Audio-Visual (PA / Intercoms / Projectors)
Communications (CB/2-way Radio/Telephones/Cell Phones/etc.)
Computers (Computers/monitors/printers/etc.)
Consumer Electronics (Radio/TV/Stereo/VCR)
Industrial (Corporate/Factory/School/etc.)
Medical (Hospital and Medical Devices)
Video Reception (Antennas/CATV/MATV/Satellite Receivers/etc.)
 Section Six: Membership Terms
I agree to abide by the VPEA Code of Ethics and VPEA Bylaws