Print this page and mail to the address below, If you have any questions email
hbphc@yahoo.com
Margaret Sells
104 W. 12th Avenue
Johnson City, TN
37604
2011 Membership Application
The Hillbilly PHC prorates membership dues...
Prorated Dues are as follows:
|
Single Dues |
Couple/Family Dues |
|
Jan-March $12.00 |
Jan-March $24.00 |
|
April-June $9.00 |
April-June $18.00 |
|
July-September $6.00 |
July-September $12.00 |
|
October-December $3.00 |
October-December $6.00 |
Make checks payable to Margaret Sells
Memo Your Check HBPHC Dues
NAME:________________________________ DATE:___________
ADDRESS:________________________________________________
CITY:____________________ STATE:______ ZIP:____________
PHONE:__________________ E-MAIL:_______________________
OCCUPATION:____________________________________________
FAVORITE BUFFETT SONG:_________________________________
BIRTHDAY:_________________________________
We are in the process of developing a membership directory.
Would you like your information included in the directory?
YES / NO. YES, but don't
include:_______________________________
Name a friend for us to contact about
membership:____________________
How should we contact them? Phone_____________ E-Mail_________
"This contribution/membership money is
not deductible as a
charitable contribution for Federal income tax
purposes."
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For office use only
Membership Paid _______ cash _________ or check#______________
T-shirts ordered_____ Paid___________________________________
Other_____________________________________________________
