Membership Form

Please print than fill out form, and return to the above address with a check made out to SRVGS.

Membership Dues:

	Individual:	$10.00
	Family:	$15.00

Please Print

Name: __________________________________________________

Address: ________________________________________________

City: _____________________ State: ____________ Zip: _________

Telephone: ______________________________________________

E-Mail Address: __________________________________________

Your information may be used in our newsletter or website

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