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 |
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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_________________________________________________________________ |
| Your membership package will include a subscription to our newsletter,
The Rodman Review, a membership card, membership decal and a bumper
sticker.
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 Kae Andry, Membership Chairman, 16891 NE 243 Place Road, Ft McCoy, Fl 32134 |
(Please put remarks at bottom of page) |
| 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.) |
| Put Remarks On The Back Please. |
Printing Hint: In most cases, if you only print the first page you should get the entire application.