Name__________________________________________Date_____________________ Dues $20.00
Note: Current Members - Only fill in information that has changed or needs correcting from last year.
Address ______________________________________ Email __________________________________
City/State/Zip_________________________________ Month and Day of Birth: ___________________
Home Phone ( )_________________ Cell Phone ( )_____________________________
For new members who join in October, November, or December, their membership will include the following year. Current members can start renewing in October for the following year. A new roster will be distributed at the March meeting. Membership form and payment can be mailed to Shirley Miller, 1632 Matt Lane, Hensley, AR 72065.