Membership Application - The International Order of the Blue Gavel Auxiliary SEP 2007

Name:

_[Surname]

_[First]

Address:

_{[Box/Apt./Street]}

_[City]

_{[Province/State]}

_{[Postal/Zip Code]}

Telephone #:

 _{[Area Code & #]}

_{[Fax #]}

Other #:

_[E-mail]

Club Name:

Spouse’s Name:

Member of IOBG:

Yes               No

District #: 25

Dues Enclosed:

Yes               No

Dues for 2008 remain at $10.00