MEMBERSHIP APPLICATION
| Check one | Check one | ||
| ONE YEAR ($20.00) | ___________ | NEW | ___________ |
| THREE YEARS ($50.00) | ___________ | RENEWAL | ___________ |
| LIFETIME ($200.00) | ___________ | ||
| EXECUTIVE COMMITTEE_($500.00) | ___________ |
| Please Print | |
| NAME:________________________________.HOME.PHONE:____________________________ | |
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ADDRESS:_________________________________________________________________________ |
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CITY:___________________________________________ STATE:_______ ZIP:__________+_______ |
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OCCUPATION:___________________________________________ |
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BUSINESS PHONE:___________________________ FAX;_______________________________ |
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E-MAIL ADDRESS_________________________________________________________________ |
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| Your membership package will include a subscription to our newsletter, The Rodman Review. Signature:_________________________________________________________________________ | |
| By virtue of my signature, I agree with the purpose for which Save Rodman Reservoir, Inc. was founded, i.e.: To preserve and protect Rodman Reservoir from destruction. I further agree to do my part in this preservation effort by convincing my friends, neighbors and acquaintances to join us in our effort. | |
| Make checks out to : Save Rodman Reservoir, Inc. and mail to: | Membership |
| Save Rodman Reservoir, Inc. | |
| PO Box 2, | |
| Palatka, Fl. 32178 | |
| A copy of the official registration and financial
information my be obtained from the division of consumer services by
calling toll free, 1-800-HELP-FLA, within the state. Registration by the
state does not imply endorsement, approval or recommendation by the state.
(this disclosure statement is required by F. S. 496.411)
Save Rodman Reservoir, Inc. is tax exempt under section 501(c)4 of the IRS code. We are not allowed to pass this exemption on to our contributors. Your contributions CAN NOT be deducted from your income tax. (This disclosure statement is required by the IRS code.) |
For Office Use Only |
| Date Received_______________________ | |
| Check #/ Cash_______________________ | |
| Entered in Database___________________ | |
| Member #__________________________ | |
| Entered in Spreadsheet________________ | |
| Entered in E-mail____________________ | |
| Membership Pkg. Mailed_______________ | |
| Put Remarks On The Back Please. | |
Printing Hint: In most cases, if you only print the first page you should get the entire application.