V.M.C.C.A. Summit City Chapter

                                                    2024

                       National, Great Lakes Region, and Chapter Dues

 

 

Name_________________________________Month/Day of Birth ______/______

 

Spouse Name__________________________ Month/Day of Birth ______/______

 

Address_______________________________________

 

City_______________State_______Zip______________

 

E-Mail________________________________________

 

Spouse E-Mail__________________________________

 

Cell Phone_____________________________________

 

Spouse Cell ____________________________________

 

Home Phone____________________________________

 

 

Annual Dues

National $48.00

G.L.R. $5.00

Chapter $10.00    Total Paid _________

 

Please fill out form to ensure our records are correct.

 

Make checks payable to: Summit City Chapter

Send to: M.D. Stitt  2014 County Rd.40  Auburn, IN  46706