| MEMBERSHIP RENEWAL/APPLICATION FORM |
Charles H. Folsom, Treasurer
434 Southfield
Road
Shreveport, LA 71106-2214
I have enclosed my check or money order for membership in the FOLSOM FAMILY ASSOCIATION OF AMERICA, INC. for the membership year ending June 30, 2010, or for Life Membership as indicated below: ($20.00 monthly payments are available for Life Memberships. See links to coupons below)
| NAME: | __________________________________________________ | |
| STREET ADDRESS: | __________________________________________________ | |
| CITY, STATE, ZIP | __________________________________________________ | |
| PHONE: | ______________________________ | |
| DATE OF BIRTH: | (Husb) ____________ | EMAIL: ____________________ |
| (Wife) _____________ | EMAIL: ____________________ | |
Please indicate type of membership:
|
[ ] |
Individual Membership |
$15.00 |
|
|
[ ] |
Family Membership (including children through age 18)* |
25.00 |
|
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Life Membership - To use coupons, print, cut out and mail each month with your payment |
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|
[ ] |
Age under 50 |
Coupons 1-10 ; Coupons 11-15 |
300.00 |
|
[ ] |
Age 50 - 60 |
Coupons 1-10 |
200.00 |
|
[ ] |
Over Age 60 |
Coupons 1-5 |
100.00 |
| Total Amount Enclosed: (Make checks payable to Folsom Family Association) | $__________ | ||
The membership year runs from July 1 through the following June 30. Canadian members: Please remit in U.S. funds. Life memberships may be paid in monthly installments (see coupons). For Family Memberships, please provide names of all family members