Member Personal Information:

Salutation

First Name    Last Name

Email Address Cell

Spouse Personal Information:

Salutation

First Name    Last Name

Email Address Cell

Home Address:

Address

City     State    Zip

Phone Fax

Summer Address:

Address

City     State    Zip

Phone Fax

Other Address:

Address

City     State    Zip

Phone Fax

Mailing Preferences:

Publicity (Newsletter) - Specify which address each month (H) Home (S) Summer (O) Other

Statements - Specify which address each month (H) Home (S) Summer (O) Other

Publicity Months:

Statements:

Children: