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Print screen, fill in the blanks, and mail to the above address

Name:_________________________________________ Spouse:_______________________________

Mailing address:___________________________ Street Address:_______________________

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Home Telephone:____________________________ Other contact number:__________ For:___

E-Mail address:____________________________


Occupation Wife:___________________________ Occupation Husband:__________________

The Association is confronted with a wide variety of issues. Your knowledge is valuable to the community. What subject(s) can you offer advice on, to help with community issues?

__________________________________________________________________________________________
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Children living at home:No___ Yes:___ Ages:____ ____ ____ ____ ____ _____ ____

(1.)Please circle the areas of interest to you. (2.) Please initial areas you will help with.

Membership drive:__________ Christmas Party:_______________ Growth/Zoning:__________

Newsletter:____________________ Special Programs:_____________________

Schools/Public Affairs:__________ History:____________ Other:_______________




_____________I want a MEMBERSHIP with voting rights--Dues $20.00 per family - per year



_____________I want an Associate Membership without voting rights--FREE


_____________I want to be removed from the mailing list. You may call 304-5100 and leave a message

____________I want to make a tax deductible contribution to the Association in the amount of

__________.

Mail dues and contributions to the above address, payable to: Ballentine-Dutch Fork Civic Association


Date received:______________________ Check#_________________________