|
Name __________________________________________
Last First
Spouses Name __________________________________
(if couple/family membership)
Address________________________________________
Street
________________________________________
City/State/Zip
Phone ( ) __________________________________
E-mail ________________________________________
___ Send the Intelligencer via e-mail
___Do not print my e-mail address in the Roster
|
MEMBERSHIP TYPE
___ Individual $25 ___ Family $30
___ Senior Citizen $20
___ Senior Couple $25
___ Contributing $50 ___ Patron $100
___ Golden Patron $200
___ Additional Contribution _________
|
