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Sign Me Up!

Pirates of the Susquehanna
Parrot Head Club - Binghamton, NY

Membership Fees are due JANUARY 1 of each year. Members who do not pay their dues by Jan. 30 will be considered
delinquent and this could prevent you from being eligible for certain perks.


Individual Membership $25/yr      April - June $18.75, July - Sept. $12.50, Oct. - Dec. $6.25


Couple/Family/Household Membership $35/yr       April - June $26.25, July - Sept. $17.50, Oct. - Dec. $8.75


(Memberships are for one household. People, including family, not living at the same address should apply separately.)
Name(s): ______________________________________________________________

Name(s): ______________________________________________________________

Address: ______________________________________________________________

City: _______________________________ State: _______ Zip: _________________

Phone: (H)___________________ (W) ___________________ (C) ________________

Email(s): _______________________________________________________________

Birthday(s): _____________________________________________________________
(Please list birthdays of additional members in the same order that their names are listed above.)
Interests: ____ Club Officer (Pres, VP, Sect.) ____ Newsletter (writing or producing)    
____ Web site (content or development) ____ Events (arranging, organizing)

____ Planning (parties, meetings)
Charities you’d like to help: ________________________________________________

How did you hear about the club: ___________________________________________

Comments: _____________________________________________________________
Membership Agreement: By applying for membership in the Pirates of the Susquehanna Parrot Head Club,
you are agreeing to abide by, and to have your membership (and the memberships of anyone whose names
appear on this application) governed by the Bylaws of the Pirates of the Susquehanna Parrot Head Club.
Signature: ______________________________   Date: ____________________

Mail completed application with check or money order made out to: Pirates of the Susquehanna PHC
PO Box 5829
Endicott, NY 13763

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