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2 0 0 6 - 5A M E M
B E R S H I P R E N E W A L
1-Print, 2-Fill-Out,
3-Enclose Dues, 4-Bring To Meeting,
or Mail To :
Amherst Astronomy Association
1403
South East ST, Amherst, MA 01002-3031
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DATE: ___/___/06
TOTAL ENCLOSED $____.___
[ ] $5 - Youth/Student/Senior [ ] $10
- Adult
[ ] $15 - Family [ ] $10
- Voluntary Add-On
All Information is CONFIDENTIAL
& NOT RELEASED without Consent
[ ]
DO NOT Release My Information
[ ] List Me on Members Page
NAME
____________________________________________________________________________
If Family, List Names
_________________________________________________________________
Address __________________________________________________________________________
Town____________________________________________ State________ Zip_________________
Home Phone (____) ______-________
Best Call Time:____________________________________
Cell Phone #
_____________________ Best Call Time:____________________________________
Work / Other Phone #s
______________________________________________________________
E-Mail
_____________________________________________________ []
Interested in E-Group
Club Program Interests
_____________________________________________________________
Personal Interests
__________________________________________________________________
_________________________________________________________________________________
Comments, Questions ?
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