Girth & Mirth of Columbus 2012 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 – - – - – - – - – - – - – -
- Second Member Name: _______________________________________________
-
- Street Address: _______________________________________________________
- City: ___________________________ State: __________ ZIP: ______________
- E-mail Address: ______________________________________________________
- 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.
PrimarySignature: ________________________________ Date: ______/_____/______
Second Signature: ________________________________ Date: ______/_____/______
- – - – Membership Fee is due at time of application and expires December 31, 2012
- – - – - Annual Membership Fee is $20 Single or $35 Couple, prorated quarterly.
- – - – - – Renewal Membership Fee is due by January 31, 2012
- – - – - – - $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
Pro Rate Schedule
Single (Couple)
If you join in this time frame, you pay the pro-rated amount listed below:
January—March 20 (35)
April—June 15 (26)
July—September 10 (17)
October—December 5 (8)
VALID JANUARY 1, 2012—DECEMBER 31, 2012