MEMBERSHIP APPLICATION (PLEASE PRINT)

Revised 10-1-17

I wish to renew my membership or join the Campbell AARP 5151 Chapter. I have enclosed a check for my annual chapter dues which include E-Mail delivery of our newsletter for $14, or Regular mail delivery for $17. I am a member of the National organization.

National No. (Required) : . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Expiration Date:. . . . . . . . . . . . . . .

E-Mail Address. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Amount Paid $ . . . . . . . . Check #. . . . . . . .

NAME:. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . [ ] New Member* (see below)

ADDRESS:. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . [ ] Renewal

CITY:. . . . . . . . . . . . . . . . . . . . . . .. . . . . . . STATE:. . . . . . . . .ZIP CODE: __ __ __ __ __ — __ __ __ __

PHONE: (. . .. . . .) . . .. . . . . . . . . . . . . . . .SIGNATURE:. . . . . . . . . . . . . . . . . . . . . . . . . . . DATE . . . . . . . .

*How did you hear about our chapter?_________________________ Age Group? 55-65 ( ) 66-75 ( ) 76+ ( )

Please make checks payable to AARP Campbell Chapter 5151.

Mail to: Membership Chairperson Shelly Schwartz or

Deliver to: Shelly Schwartz at Campbell Community Center, Q80, on November 19, 2017