Please print all information clearly

===============Detach and Mail Today================

 
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 2015
 
______ Additional dues of $ ______ for 2016 ____, 2017 ____, 2018 ____, 2019______
 
______ 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 ______