IOBG District 25 - Membership Application

                              New Member                                  Renewing Member 

Name:
Spouse Name:
Address:
City:
State:	Zip or Postal Code:
Country:
Email Address:
Home Telephone:
Work Telephone:
FAX Number:
Chapter Name:
Chapter Office:    (Only if you are a Chapter Officer)
Chapter Contact:
Winter Address:
Winter City:
Winter State:	Zip or Postal Code:
Country:
IOBG Dues Submitted:	$50.00US
Year you were commodore:

Make all Checks and Money Orders payable to IOBG – District 25

Send completed to:                     District Treasurer P/C Robert Zasada

                                                     519 Emmons Blvd.

                                                    Lincoln Park, MI. 48146