Name: _______________________________________________________
Street Address: ________________________________________________
City: _________________________________ Zip Code:______________
Phone: _______________________________
Email Address: ________________________________________________
Date of Application: _____________________________________________
Dues (check one) :
___ $20 for Attorneys
___ $10 for Judges
___ $10 for Students
Make check payable to GPWBA and remit payment to Treasurer:
Kristina Beavers
PO Box 2501
Yorktown, VA 23692