Name
_____________________________________ Phone No.
__________________________
Address
__________________________ City___________________
State______ Zip_______
E-mail
address
_________________________________________________________________
Check
One ______Regular [50 and over] ______
Auxiliary [49 and under]
Retired?
____ Working? _____Previous career or current occupation
__________________
Hobbies
and areas of interest:
____________________________________________________
Check
One ______New member
______ Renewal
Amount
paid $______________________
2009
Membership Fee Date Paid_________________
New members may pro-rate the first year @$2.50 per month
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