Girth & Mirth of Columbus 2010 MEMBERSHIP APPLICATION

 

PLEASE PRINT

Membership:  New: _____   Renewal _____  Type:  Individual _____   Couple _____

 

Primary Member Name: _________________________________________________

Street Address: _________________________________________________________

City: ___________________________   State: __________  ZIP: ________________

E-mail Address: _________________________________________________________

Phone: (_______)  ________________________  D.O.B: _______/______/_________

-   -   -   -   -   -   -  -   -   for couples membership   -   -   -   -   -  -   -   -   -   -   -   -   -   -

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-  Second Member Name: _______________________________________________
-

-  Street Address: _______________________________________________________
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-  City: ___________________________   State: __________   ZIP: ______________
-

-  E-mail Address: ______________________________________________________
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-  Phone: (_______) _______________________   D.O.B: _______/______/________
-   -   -  -   -   -   -   -   -   -   -   -   -  -   -   -   -   -   -   -   -   -   -  -   -   -   -   -   -   -   -   -

Is it O.K. to send you club mailings via USPS?  Yes ____   No ____

Do you wish to keep your information private from other members?  Yes ____   No ____

I hereby certify by signature that I am at least 21 years of age, and agree to abide

 by all club By-Laws, rules, and regulations.

Primary Signature: ________________________________   Date: ______/_____/______

 

Second Signature: ________________________________   Date: ______/_____/______

 

 

-  - - - Membership Fee is due at time of application and expires December 31.

- - - - - Annual Membership Fee is $20 Single or $35 Couple, prorated quarterly.

- - - - - - Renewal Membership Fee is due by January 31.

- - - - - - - $25.00 returned check fee.  Do not send cash by mail.

 

     - - - Please mail to - - - - - - - -
       Girth & Mirth of Columbus
       P.O. Box 1062
       Columbus OH 43216-1062