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MEMBERSHIP APPLICATION
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MEMBERSHIP APPLICATION
In order for your contact information to appear properly, include your information as you wish it to appear in the 2018-2019 Membership Directory.
Membership Type:
*
Renewal
New Member
Select One:
*
Miss
Ms.
Mrs.
Dr.
Mr.
Mr. & Mrs.
Drs.
Dr. & Mrs.
Mr. & Dr.
Name
*
First
Last
EMAIL
Would you like us to publish your e-mail address in our Directory? It is not shared with anyone outside of our organization.
*
Yes
No
Would you to reserve a full page ad in our Directory?
*
Yes
No
Please include an additional payment of $100 for a full page Black and White ad. All artwork must be submitted no later than September 15th of each year. Color ads are also available. An ad may be a friend's page, words of encouragement or a business.
Address
Street Address
Address Line 2
City
State / Province / Region
ZIP / Postal Code
HOME PHONE
CELL PHONE
BUSINESS PHONE
FAX NUMBER
Please call on me to volunteer in the following area(s):
Chairing an event
Join a committee
Underwriting
Find sponsors for events
Hostess
Raffle and/or Silent Auction
Facebook or Website maintenance
Photographer
Historian
Where needed
MEMBERSHIP CATEGORY
*
Individual Membership: $30.00
Family Membership: $50.00
Silver Sword Membership: $100.00
Corporate Membership: $500.00
Life Membership: $1000.00
ADDITIONAL CONTRIBUTION:
Credit Card
American Express
Discover
MasterCard
Visa
Card Number
Month
01
02
03
04
05
06
07
08
09
10
11
12
Year
2019
2020
2021
2022
2023
2024
2025
2026
2027
2028
2029
2030
2031
2032
2033
2034
2035
2036
2037
2038
Expiration Date
Security Code
Cardholder Name
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