Application for
Residence Status on
A Southern Oregon
and Northern California
Star Trek Fan Club
To apply please print out this form and mail to the adress on the bottom of the page with your membership dues.
Date: ____/____/____
Name: _________________________________________________________
Address: ______________________________________________________
City: ______________ State: ______ Zip: __________
Home Phone: (____)_____-_______ Message Phone: (____)_____-_______
Please Answer the following questions:
How often do you watch Star Trek?_____________________
Which Star Trek program do you watch the most often?
A. The Classic Star Trek (Kirk-Spock, etc) _____
B. The Next Generation (Picard-Riker, etc) _____
C. Deep Space Nine (Sisko-Odo, etc) _____
D. Voyager (Capt. Janeway-Paris, etc) ____
How many hours per month can you spare for club meeetings? __________
What would be the best day and time for you to attend the monthly meeting? ____________
Signature: __________________________________
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Additional Information
Membership meetings will be held.
Membership dues will be $5.00 per month or $30.00 per year
Starbase OR.CA newsletter only $10.00 per year U.S. resident
$15.00 per year for all others
Club information will be posted in the following media types: Medford Mail Tribune, Grants Pass Daily Courier, Klamath Falls and Northern California Newspapers
Make Checks or money orders payable to (No cash please)
Paul Walker Jr.
Club Organizer and Current President
P.O. Box 131
Rogue River, OR 97537
