Chugiak Senior Center

YOU DON'T HAVE TO BE A SENIOR TO BE A MEMBER!

Application for Membership

Chugiak Senior Citizens, Inc., 22424 N. Birchwood Loop, Chugiak AK 99567 (907) 688-2677

Sign me up as a    VOTING*   ASSOCIATE* member.

  Enclosed is my membership fee in the amount of: $20.00 for individual membership ($30.00 for a couple).

  I'd like to become a Lifetime Member. Enclosed is my one-time membership fee of $125.00.

  Please sign us up as a Business Member. Enclosed is payment of $25.00

Name: ____________________________________________     Birth date: _________________

Residence Address: (city/state) ____________________________________________________

Home Phone: ____________________     Work Phone: _____________________

Mailing address: ______________________________________________________________

   Return your membership form with remittance to:

    Chugiak Senior Center
    Members
    22424 N. Birchwood Loop
    Chugiak, AK 99567

    Phone: (907) 688-2677
    Fax: (907) 688-1319