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Kiwanis Club of Mount Airy

Membership Application

 

Please Print

 

Name:_________________________ Nickname:__________ M:_____F:_____

Mail Address:___________________City:____________St:______Zip:______

Bus. Address:___________________City:____________St:______Zip:______

Home Phone:____-_______ Business Phone:____-________Fax:____-_______

Kiwanis Sponser:______________________Former Kiwanian? Yes:___No:___

Email Adr:__________________Web Page: ___________________________

Birthdate:__________Spouse Name:___________Children:________________

Memberships:____________________________________________________

Education Level:_________________Interests:__________________________

Dues $145/Year, Payable $36.25/Qtr
Make Check to: Mount Airy Kiwanis Club
 

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