2012 MSC Membership Application Form

Payment of dues for the upcoming year (Nov. 1, 2011 - Oct. 31, 2012) may be made by mail or at the fall banquet. If you wish to become a member, please complete the following form and enclose $8 per person. An additional gift, which is tax deductible, will be very much appreciated. A list of all members will be published in the next Newsletter.

NAME/NAMES           ___________________________________________________

MAILING ADDRESS ___________________________________________________

                                      ___________________________________________________

ZIP CODE                   _______________ 

PHONE                       ____-____-______

E-mail address          _________________________________

ENCLOSED    2012 DUES    $____________

                         2012 GIFT      $____________

Please make checks payable to :    Manchester Shepherd's Center

(Your canceled check will serve as your receipt.)

Thank you.