Annual Membership Application Form
|
O New |
O Renewal |
||
| Name | |||
| Address | |||
| City, State, Zip |
_____________________________________ |
____ |
________ |
| Telephone |
(
) ________ - ___________________ |
||
| Please Select Appropriate Membership Level | ||
| Retirees | O Single $20.00 | O Couple $25.00 |
| Basic | O Student $10.00 | O Single $25.00 |
| O Family $35.00 | ||
| The Heritage
Club |
O Sponsor $85.00 | O Benefactor $150.00 |
|
O Patron $500.00 |
O President's Circle $1,000.00 |
|
|
Enclosed is my check number |
________ |
in the amount |
|
|
Bill my credit card: |
O MasterCard | O Visa | O American Express |
|
Card Number: |
__________-__________-_________-_________-_________ | ||
|
Expiration Date: |
____________ / ____________ (Month / Year) | ||
|
Name on card: |
____________________________________________ (Please Print) | ||
|
Signature: |
_____________________________________________________ | ||
Mail form to OMAM, 78 E. Granada Blvd, Ormond Beach, FL 32176
Questions? Call (386) 676-3347
OMAM is a U.S. Code Title 26 Section 501(c)(3) non-profit organization,
registered with the State of Florida
Department of Agriculture and Consumer Services.
Registration Number: SC07333.
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All rights reserved.
This web page was updated on
29-Sep-2004 02:08 PM -0500