MEMBERSHIP APPLICATION FORM
Please print and fill out form

NAME____________________________ NAME______________________________

ADDRESS________________________ ADDRESS_________________________

                   _________________________                   __________________________

PHONE___________________________ PHONE____________________________

Membership is from July 1, 2009 to June 30, 2010. The membership fee is $20.00 per person. Lifetime Memberships are also available for a one-time fee of $300.00.

(Please see the brochure entitled " Homer Senior Citizens, Inc. Services and Membership" for more information on membership benefits.) (Available In our office.)

Enclosed is $________ in payment for_____ (one or two) membership (s) for FY 2010

Lifetime Membership $____________________

Please return this printed form with payment to:

Homer Senior Citizens, Inc.
3935 Svedlund
Homer, Alaska 99603

Or drop it by our main office at the same address.

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