Atlanta Parrot Head Club

Membership Form

 

 

 

Name (s): ____________________________________________________

Street Address:_________________________________________________

City/State/Zip:_________________________________________________

 

Phone Number(s) including Area Code: _____________________________

Is it OK to add your phone number(s) to the next club roster printed?  (circle) YES or NO

 

E-Mail Address: ________________________  Birthdate(s): _______________

Is it OK to add your email address(es) to the next club roster printed?  (circle) YES or NO
 

Favorite Buffett Song? _________________________________________
Occupation ___________________________________________________

 

Can you help on a committee? ( Please check all that you are interested in)

___________________________________________________________

 

Membership Dues are collected when you join.

Cash or Check Payable to:

"Atlanta Parrot Head Club"

c/o Ann Gotthelf, Golden Fleece Jewelry
2300 Peachtree Road
Suite B-206
Atlanta, GA 30309
 

I am paying for:  (check all that apply)

$20 for one year, one person ______

$30 for one year, per couple ______

 

 

For Office Use Only:  Who collected form/pmt? _______  Assigned to caller _______

Added to Member List _____ Added to Newsletter List _______