Membership Application
Please Print:Date: _____________________

Name: ______________________________________

Street: __________________________________________

City: ________________________   State: AR   Zip: ________

Home Ph: ___________    Cell: ___________    Work: ___________

Email Address: ______________________________________________

Spouse Name: ______________________________________________
     Associate Member: ___ Yes    -- *Women may Join as an Associate Members

Sponsored by: Dr. Bill Smith or _____________________________

DUES: Men: $25/yr ea. Women - Assoc Member: $15/yr ea. Membership year: Jan-Dec. Dues are due in January. After April 1st, new applicant dues are prorated at $2.00 per month for regular member and $1.25 per month. There is an initial $2.00 fee for a name badge. Dues: $25/ea or $15/ea + Badge Fee: $2/ea = $_________

Activity Interests (check off)
Entertainment: _____
Publicity: _____
Letters to editor: _____
Community Relations: _____
Public Office: _____
Fair Booth: ______
Sign Placement: _____ 		Club Promotion: _____
Canvassing: _____
Campaign Support: _____
Membership Development: ______
Fund Raising: _____
Annual Breakfasts: ______
Other:___________________

Bring application & payment to the next meeting
Or mail to: David Witherington, 1870 CR 15, Mountain Home, AR 72653