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Loyal Escorts of the Green Garter
Check applicable box: New, Term New, Life Renewal Life Reinstated Name: Last: First: MI: Home Address: Street: P.O. Box: Apt. #
City: State: ZIP Code: E-mail: Telephone: () DOB (Mo/Day/Yr): Sponsor Name: Relationship: Sponsor Chapter Code (i.e., MI-2): SSN: (need for accounting) Term 2 year -- $25 Life 40 & Under -- $175 41 - 45 -- $145 46 - 60 -- $125 61 -70 --- $100 71 -80 -- $75 81and over --- $50 Signature:________________________________________________ Date: ___________________ MAKE CHECK PAYABLE TO LOYAL ESCORTS OF THE GREEN GARTER AND MAIL TO: Loyal Escorts of the Green Garter Jeanne Cantrell Treasurer, If you are a snowbird please print below your snowbird address along with the stop and start dates. Snowbird Address: Street: P.O. Box: Apt. #
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