SAS of the GOLD COAST
2010 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

Comments:            

Membership fees for 2010: 

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 February 15^th, 2010.

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
561-842-6098