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Tri-Village Sertoma |
Type of Membership:
___Charter ___Active ___Transfer ___Reinstated ___Associate ___Transfer Life ___Reinstated Life
| I hereby make application for membership in the Tri-Village Sertoma Club and accompany this application with a remittance of $25.00 in payment of the membership fee. I accept and subscribe to the provisions of the club constitution and by-laws. |
Applicant:__________________________________________ Date: _______________
Representing: _____________________________________ Position: ______________
Please indicate desired mailing address, either business or residence.
____ Business Address____________________________________________________
City_____________________________ State_______________ ZIP_______________
Phone_____________________________ Fax_______________________________
E-Mail__________________________________________________________________
____ Residence Address___________________________________________________
City_____________________________ State_______________ ZIP_______________
Phone_____________________________ Fax_______________________________
E-Mail__________________________________________________________________
_____ Individual Membership? ____ Business Membership?
Spouse’s Name:__________________________________________________________
Applicants Date of Birth____________________________________________________
How would you like to receive bulletin? ___E-Mail ___Mail ___Fax
Sponsoring Members Name: _________________________________________
Print this form using the printer button in your browser. Complete the form and return it to you sponsoring club member.
