Name: ____________________________________________________

Address: __________________________________________________

City/Zip: _________________ Phone #: _________________________

E-Mail: ___________________________ Birth Date _______________

Sponsor: ______________________________________

Index: _______ actual or estimated   NCGA #: _____________________
                                (circle one)

Current Dues 2024:  $85

I have read the membership guidelines and agree to abide by them:


Signature: ________________________________ Date: _______________

I would like to volunteer as a Scheduler or Collector in the future
                                                        (circle one)

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Board use only:
Dues Received: _________________ Date: ________________
Membership Requirements Met: _________________________
Board Acceptance Date: _______________________________
Date Notified: _______________________________________

March 2020