SAS of the GOLD COAST
2012 Membership Registration 

Last Name:                                              

First Name:                                  

Address:                                                                                                     

City:                                                                                                           

State:                           Zip:             

Home Phone:                                                                    Cell:

Work Phone:                                                                     Fax:                                         

E-mail:                                                                                        
    

Names of Family Member(s) and Children age(s):      

I would like to donate time to the Society:              YES                 NO
I would like to provide a place for an event:             YES                 NO

I was told about the club by: __________________________

Comments:            

Membership fees for 2011: 

Family: $40.00                   Single: $25.00               Single parent with children: $40.00

After September membership fees are 50%. After December, membership fees will apply to the entire next year. If you do NOT have access to the internet, add $5.00 to the above fee. Your correspondence will be mailed to your home or office. Membership fees are due by January 31st, 2012.

Make check payable to the Swiss American Society of the Gold Coast and
mail this form with your check to:

Benjamine Bambauer
3077 Laurel Ridge Cir.
Riviera Beach, FL 33404
561-644-3298