Please complete all the relevant items. Send the form along with your membership* fee
(Payable to VPA-EAST) to Ms. Meena Gowda, 1920 Chapel Hill Road, Silver Spring, MD 20906-1117.
1. ___________________________________________________________________
First Name Last Name Spouse
2. ___________________________________________________________________
Address
___________________________________________________________________
Address
3. __________________________________________________________________
Home Phone Office Phone
__________________________________________________________________
Fax E-mail
4. Names of Children Age Areas of Interest
(a) __________________________________________________________________
(b) __________________________________________________________________
(c) __________________________________________________________________
(d) __________________________________________________________________
6. Membership Fee enclosed:
Single $20 Family $40 Life $500 Patron $1000 Grand Patron $5000
*Ignore this if you are already a Life Member/Patron/Grand Patron.
You can become a Life Member by paying $500 in installments of $125 over four years.