VOSH-NORTHWEST
12649 93rd Pl NE
Kirkland, WA 98034
DUES APPLICATION FORM
NOTE: To join VOSH NORTHWEST, make your tax deductible contribution of $35.00 (or $10 for Students) by printing this form, filling it out, and mailing it with your check to the address above. (Note: This form cannot be filled out on-line)
Date: ______________________ ENTER DUES AMOUNT TO BE PAID: $_____________
ANY ADDITIONAL DONATION: $_____________
CHECK TOTAL AMOUNT: $_____________
NAME:________________________________________________________________________________
(how you want your name listed)Title (e.g. Mr., Ms., Dr., etc) ____________________
License (e.g. OD, MD, PHD, LDO, etc.)__________________
ADDRESS:________________________________________________________________________
CITY_______________________________________________,STATE___________________________ZIP:_____________
Please list one contact phone number: Work, Home, Cell (circle which applies) (_______) ________ -_____________
PLEASE provide us with your E-Mail Address: (Very Important as this is how we communicate with you)
______________________________________________________________________________________________
Make checks payable to VOSH-NORTHWEST and mail to the above address
