American Czech-Slovak Cultural Club

American Czech-Slovak Cultural Club
Phone: (305) 891-9130
Email:[email protected]
Internet: http://acscc.org
13325 Arch Creek Road
North Miami, Florida 33181-1905
PŘIHLÁŠKA
APPLICATION FOR MEMBERSHIP
Datum (Date)
Jméno (Name)
__________________________________________________________
Adresa (Address)
________________________________________________________
Město/Stát/PSÉ (City/State/Zip)
____________________________________________________________________
Telefon (Telephone)
_______________________________________________
Email
___________________________________________
Místo narození (Birthplace)
___________________________________________
Datum narození (Date of birth)
_________________________________________
Doporučen kým (Recommended by)
Podpis (Signed by applicant )
Datum (Date Signed )
___________________________
_____________________________
ANNUAL DUES
Standard Membership - $60.00
Young Adult Membership* - $25.00
Please make checks out to ACSCC
Please send your completed form and a check for dues to:
American Czech/Slovak Cultural Club
13325 Arch Creek Road
North Miami, Florida 13181
Attn: Treasurer
*Less than 30 years of age.
For ACSCC use only
Date dues received.
Standard membership ($60.00) _______________________________
Young adult membership ($25.00) _______________________________
File: acsccmembershipform_041612_web.pub