Dr Sarju Shah M.D

2008)
Gujarati Samaj Of Detroit
2008 Membership Form (Membership from January 1, 2008 to December 31,
Date: _ ____ Membership form also available on www.GSOD.org
MEMBERSHIP RENEWAL
Renew my membership based on last year’s profile
Skip Section 1 & Complete Section 3 of the form.
LIFE MEMBER – UPDATE INFO
I am Life Member, please change/update my information
Skip Section 2 & 3 of the form.
If Renewal, please provide Membership Number here:
SECTION 1: FAMILY MEMBERSHIP
Member’s full name:
Member’s Spouse name:
Number of Children (under 18 years):
Street Address:
City: State: MI Zip:
Telephone (required):
Email:
Samaj will maintain address and e-mail information with strict confidence and will not be used or given to others for solicitation
Parents: Senior Membership is available at $25/-
Fathers Name:
Mothers Name:
SECTION 2: MEMBERSHIP & FEES
Family Membership
Husband, wife, and unmarried children under 25 years of age and
parents living in the same household
$45
Single Membership Single as defined by IRS $25
Senior Membership One spouse of 62 years of age and above $25
Student Membership
Full time student (18 years of age and above)
(copy of Student ID required)
Life Membership Samaj’s Lifetime affiliation! $500
SECTION 3: ACKNOWLEDGEMENT & AUTHORIZATION
I, undersigned understand that this membership application will be reviewed by the
Secretary of Gujarati Samaj of Detroit. The above information is true and correct to the best of my knowledge. I understand that any
misrepresentation or falsification will result in the cancellation of my membership. I will be responsible for non-member fees if the
membership was used during any of the Samaj’s programs, such as Holi Celebration, Navratri, Diwali and other events.
$15
SIGNATURE: _______________________ DATE: ___________
Please Make Check Payable to: Gujarati Samaj of Detroit
Form & Check Mailing Address: Nimish Pathak, 46728 Doubletree Rd., Canton MI 48187
Questions? Email us at Secretary@GSOD.org
FOR OFFICIAL USE ONLY:
We hereby acknowledge the receipt of payment for 2008 Samaj Membership:
Date Received:
Secretary:
“A truly happy person is one who can enjoy the scenery on a detour”