Make your own free website on Tripod.com

Membership Renewal Form    For Fiscal year beginning April 1, 20_____

Monrovia Rockhounds

P.O. Box 553  

Monrovia, CA 91017-0553      

 

Please print your information.  Use only the address above if you are renewing by mail and please do not mail cash.

           

NAME________________________________________________________________

 

FULL ADDRESS________________________________________________________

(  ) I want my address on the roster     (  ) I do not want my address on the roster

 

HOME PHONE:  ______________________________

 

CELL PHONE:  _______________________________                

(  ) I want my phones on the roster      (  ) I do not want my phones on the roster

 

BIRTHDAY:  (month/day only)  ________________

(  ) I want my birthday on the roster      (  ) I do not want my birthday on the roster

 

E-MAIL ___________________________________________

(  ) I want my email on the roster      (  ) I do not want my email on the roster

 

FIRST/LAST NAMES OF FAMILY MEMBERS: 

 

______________________________________________________________________

 

 

 

Renewal Fees    Individual Membership  $20.00………………………………$_________

                           Each additional person in same household $10.00 each ...$_________

                    

Amount of dues received $________ Check #________ Cash $_______ Date________                                              

Received by (signature) ________________________________