FORM FOR MEMBERSHIP RENEWAL ONLY
Date:
_________________ Enclosed is $ ___________ for ______ year(s) dues.Last Name: ______________________________ His: ________________ Hers: _______________
Street Address / PO Box: ____________________________________________________________
Town / City: _____________________________ State: ___________ ZIP Code: _______________
Home Telephone: (_____) _______________________
Cell Phone(s): His (_____) _______________________ Hers (_____) ________________________
E-mail: ___________________________________________________________________________
(Please print CLEARLY and EXACTLY the way you want it)
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Mail to:
Jan Woods, PO Box 2217, Florence, OR 97439-0145
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