Registration Form

Membership Application Form
Gateway Professional Partners Chapter
National and Local Chapter Membership 

First Name: _________________________________

Last Name: _________________________________

E-mail Address: _________________________________________________________________

Address: ______________________________________________________________________ 

City: ______________________________   State: ______  Zip: _____________  Country: _USA_

Phone: ( _____ ) - _____ - ________   Fax: ( _____ ) - _____ - ________  

EWB Chapter:  __Gateway_Professional_Partners_    Currently an EWB-USA member*  _______

Profession:  ___________________________________________________________________

 Affiliations:      ASME                ASCE          ASFE            AIA              ACEC/MO
                         MSPE                 ISPE            SWE             DBIA             ACEC/IL
                         SAME                IEEE             AEG             AIPG             ENG CLUB
                         NAWIC              CHMM          APWA          AGC/StL    


 Area of Interest: _______________________________________________________________                           


Please submit this application and a check for $110* made out to EWB-USA to:
                                       Theresa Hlavinka, EIT
                                       Black & Veatch Corporation
                                       15450 South Outer Forty Drive
                                       Suite 200
                                       Chesterfield, MO 63107

                                       Questions: 636-532-1051 ext. 111  This e-mail address is being protected from spam bots, you need JavaScript enabled to view it

Fee includes:
$100    Annual dues for EWB-USA (Professional Member)
$10    Annual dues of $10 for Gateway Professional Partners Chapter
*Existing members of EWB-USA only need to provide the $10 for local Chapter dues
All funds will be forwarded to EWB-USA for processing.
Please register at

Please accept my additional donation of $______ for the Gateway Professional Partners Chapter of Engineers Without Borders.

Please contact me about serving on an EWB Committee  ___