| |
| Name:____________________________________________________________________ |
| Spouses Name if Joint
Membership__________________________________ |
| Address:
__________________________________________Date Retired: ____________ |
| City:
_____________________________ State: ___________ Zip:
_______-________ |
| Home Telephone No:
(____)__________________________________ |
| Work Telephone No:
(____)__________________________________ |
| Cell Telephone No:
(____)__________________________________ |
| E-Mail Address:
_____________________________________________________________
|
|
|
|
____ Check
this box if any of the above information is a change from last year |
|
|
|
Make check payable to: the Phoenix Society, Inc. and mail
to |
| P.O. BOX 64,
ANNAPOLIS JUNCTION, MD. 20701-0064 |
| |
| ______ Check
enclosed for $25, dues for 2008 |
| ______ Additional dues of $ ______ for
2008 ____, 2009 ____, 2010 ____, 2011______ |
| ______ Check enclosed for $______ for a
Life Membership |
|
(Age 55-60 is $800; Age 61-69 is $600; Age 70+ is $400) |
| |
| FOR OFFICE USE ONLY: |
|
Date Rec’d____/____/____ Amt
rec'd $_______ Initials _______Ck#________ Cash ______
|
|
|
|
|