Membership Application

 

Date_______________

 

 

 

First Name________________________ Last Name____________________

Street________________________________________________________

____________________________________________________________

City____________________________________ State___ Zip___________

Home Phone ____ ___ ____ Cell Phone____ ___ ____ Other _______ ____

E-mail address__________________________________________________

Business Name__________________________________________________

 

 

The club meets on the 4th Thursday of every month.

Dues are $35.00 per year.

Please make checks payable to Pachyderms of GBR.

Mail to:          AngelaNeff, Treasurer

2525 West Orice Roth Rd. #901

Gonzales, LA 70737