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2010 - 5A MEMBERSHIP RENEWAL
1-Print, 2-Fill-Out,
3-Enclose Dues, 4-Bring To Meeting,
or Mail To :
Tom Whitney - Amherst Astronomy Association
1403
South East ST, Amherst, MA 01002-3031
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DATE: ___/___/__
TOTAL ENCLOSED $____.___
[ ] $5 - Youth/Student/Senior [ ] $10
- Adult
[ ] $15 - Family [ ] $10
- Voluntary Add-On
All Information is CONFIDENTIAL
& NOT RELEASED without Your Consent
[ ]
DO NOT Release My Information
[ ] List Me on Members Page
NAME
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If Family, List Names
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Address ___________________________________________________________________________________
Town______________________________________________________ State_______ Zip_________________
Home Phone (____) ______-________
Best Call Time:______________________________________________
Cell Phone #
_____________________ Best Call Time:______________________________________________
Work / Other Phone #s
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E-Mail
______________________________________________________________ []
Interested in E-Group
Club Program Interests
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Personal Interests
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Comments, Questions _______________________________________________________________________
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