Year 2006 Membership Renew/Application Form
Get PDF Format Application form
Please check one of the following membership types: (Expires 12/31/2006)
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Corporate – Gold |
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$1,200.00 |
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Corporate – Silver |
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$700.00 |
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Corporate – Bronz |
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$400.00 |
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Corporate – Support |
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$200.00 |
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Contributing |
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$100.00 |
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Family |
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$40.00 |
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Individual |
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$25.00 |
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Full Time Student |
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$20.00 |
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Mr./Mrs./Ms:____ First Name___________________ Last Name:__________________________
Company Name:_________________________________________________________________
If student membership, please list name of your school._________________________________
If family membership, please list members names:
Mr./Mrs./Ms:____ First Name___________________ Last Name:__________________________
Mr./Mrs./Ms:____ First Name___________________ Last Name:__________________________
Mr./Mrs./Ms:____ First Name___________________ Last Name:__________________________
Mr./Mrs./Ms:____ First Name___________________ Last Name:__________________________
Address_________________________________________________________________________
Town: _____________________________________________ State:_____ Zip Code:_______
Home Phone:_______________________ Work Phone:_______________________________
E-Mail ______________________________________________________________________
Wich Activities would you like to participate? _____________________________
How much would you donate? School Visitation Program $___________
General Found $___________
Total with membership enclosed $___________
Please complete the form above and send with a check payable to JASC to the following address:
Japan-America Society of Connecticut
PO Box 252
Plainville, CT 06062 USA