India Festival Souvenir Book-2009 (Part 4)

India Festival 2009
Gujarati Samaj of Tampa Bay
MEMBERSHIP FORM
Year2010
www.gujaratisamaj.org
Office Use Only I.D. no: _________
Amount: $ _________Date: _______
Cash/Check #:
Received by:
If address, phone # change, Please Check Here
Membership Year from January 1, 2010 through December 31, 2010
(Please use CAPITAL letters only to avoid errors in the membership directory.)
Annual Fee
Up to 12/31/09 After 1/1/2010
1. Primary Member: $65.00 $75.00
(Last Name, First Name, Middle Initial)
2. Spouse Name: $65.00 $75.00
(Married Children and others living in the household)
Name Relationship Sex Age
3. $65.00 $75.00
4. $65.00 $75.00
5. $65.00 $75.00
6. $65.00 $75.00
(Unmarried Children age 5 to 25, Senior Parents 60+, Non Working, Living with the Primary Member only)
7. $40.00 $50.00
8. $40.00 $50.00
9. $40.00 $50.00
10. $40.00 $50.00
11. $40.00 $50.00
Please make check payable to: Gujarati Samaj of Tampa Bay TOTAL _____ ____
There may be a nominal charge for some events for all members.
This membership is Non - transferable & Non - refundable.
E-mail Address:
Mailing Address:
City: State: Zip: _______________
Phone H: W: Cell: ______________ Fax:
Please mail To: Gujarati Samaj of Tampa Bay
Kanti Bakarania
1209 Belladonna Drive
Brandon, FL 33510
(813) 653-4981
Deadline for inclusion in directory:
December 31, 2009
CASH RECEIPT
Year 2010
Please make sure that this box is completed by
GSTB office when you pay CASH.
Your Name:
Address:
Office Use Only I.D. no: ___________
Amount: $_________Date: _________
Cash/Check #: ________
Received by: _____________
www.gujaratisamaj.org
89 Gujarati Samaj of Tampa Bay