PLEASE PRINT----------------Lifetime Membership Application-------------
Fees Are Not Refundable---------

Stanislaus Memorial Society, Inc. P.O.Box 4252 Modesto, CA, 95352-4252
Telephone: (209-521-7690
To enroll in this Society, I have enclosed:
______$25 for each adult
______$10 for each child
______$10 transfer fee

Name(s) ______________________________________________________________________

________________ Date ___________

Mailing address _________________________________________________________________

______________________________________________________________________________

City _____________________________________ Zip code _____________________

Telephone_(       )_____________________________

Minor dependent children to be covered by membership (names and birth dates)___________________

________________________________________________________________________________

_______________________________________________________________________________

How did you hear about us? ________________________________________
Are you a veteran? ____________________________

Please accept this gift to the Society (in addition to membership fees) $___________________________

$______ to carry out educational programs

$______ Memorial Gift in memory of   ___________________________________________________

Please feel free to make copies of this information to give to friends and relatives.
* To validate your membership card, you must IMMEDIATELY return the forms we are mailing to you.
Note: Postage is a large expense in a nonprofit organization, so we would appreciate it very much if you
would enclose two first-class stamps (no envelope) with this application.