Please provide the following
information for our membership records.
NAME: ___________________ _______________________ _________________
Last First, Middle Initial Spouse
ADDRESS:___________________________________________________________________
_______________________________________________________________________
City State Postal Code Country
_______________________________________________________________________
Home
Phone E-mail
Address
_______________________________________________________________________
FAX Home
page
From:__________To:________ _______ _______ __________
Dates on Sampson Hull No. Division Rank/Rating
Birthday________________
(MM/DD/YY)
______
Please register me as a REGULAR Member with full voting rights and send me a
copy of Association Roster, By-Laws, periodic newsletter and all Notice
mailings. I enclose $10.00 Annual Dues.
______
Please register me and/or my Spouse as an ASSOCIATE Member and send me a copy
of By-laws and all Notice mailings. I
enclose $5.00 Annual Dues.
PLEASE return to: Dave Brandt, Secretary
1
Ridge Lake Drive
Along with check, payable to USS Sampson
Assn. for Annual Dues or Additional Donations.