Name____________________________________ 2017 Dues $20.00
Year you joined SCQG _______________ Lifetime Member _____Yes _____No
Note: current members - only fill in information that has changed or needs corrected from last year.
Address _____________________________ Email _____________________________________
City/State/ZIP__________________________________ Month and Day of Birth_______________
Home Phone ( ) __________________ Cell Phone ( ) ______________________
Lifetime members are those who have maintained their membership for a minimum of 10 years and
have had 75th birthday before January 1, 2017.
For new members who join in Oct., Nov., or Dec., their membership will include the following year.
Current Members can start renewing in November for the following year.
A new roster will be distributed at the February meeting.
Membership form can be mailed to Shirley Miller, 1632 Matt Lane, Hensley, AR. 72065 or emailed to