Date:__________________ Membership #: _______________________ Annual Membership Dues: $25.00

Mr.

Mrs.

Last Name: ______________________________________________ First: Ms.___________________________

Address:_______________________________________________ City:______________________________

Zip Code:___________ Home Phone: ________________________ Bus. Phone: ________________________

Occupation:______________________________________________________

E-Mail Address: _____________________________________________________________________________

How did you learn about CCUG-PC? (ex: Which newspaper? Name of friend/relative?)_________________________

__________________________________________________________________________________________

THREE MOST FREQUENTLY USED PROGRAMS:	LEVEL OF EXPERTISE: BEGINNER, INTERMEDIATE, OR ADVANCED

CCUG-PC publishes all membership information unless otherwise indicated:________________________________

__________________________________________________________________________________________

Our group has many uses for your talents. We will be happy to explain the functions of each committee needing assistance. If you are able, please let us know if you can assist in various activities within the group, such as:

Newsletter _____Telephone Committee ____Raffles/Drawings

Setup _____Membership ____SIG Leader

Nominating _____Photography/video ____Advertising

Information Table _____Holiday Party ____Special Events
Other

APP:LB-7/01