|
Membership Application
Form
General Information:
Name: __________________________________________________
Spouse's Name: ___________________________________________
Children's Names: ________________________________________________
Childrens Birthdays: ________________________________________________
Address: ________________________________________________________
City: _____________________________ State:
_____ ZIP: __________
Work Phone: ___________________ Home Phone: _____________________
Email: ________________________________ Fax: _____________________
Personal Information:
Country of origin: ______________________________ State of origin: ______
Spouse's country of origin: _______________________ State of origin: _______
Countries you livided in: ____________________________________________
Languages you speak: _____________________________________________
Annual Membership Catagories/Fees (Circle one)
Family: $30.00 Individual:
$15.00 Student: $7:00
Corporate: ____
I accept liability for personal loss or injury at any BrazIndy function that I and my
family members attend.
Signature: _____________________________________ Date:
_________
Please make check payable to:
and mail to:
BRAZINDY
BRAZINDY
7045 B American Way,
Indianapolis, IN 46256
|