THE FUNERAL CONSUMER SOCIETY OF COLORADO

MEMBERSHIP APPLICATION

Names of adult applicants: _____________________________________________________

___________________________________________________________________________

Street address: _______________________________________________________________

___________________________________________________________________________

City, State, Zip: ______________________________________________________________

Eligible Dependents (List Name and Year of Birth): ________________________________________________________________________

______________________________________________________________________________

(Dependent minors listed on your federal income tax form

are considered family members at no extra charge.)

Phone number:

Number of adult applicants _________ X $10.00

Total amount enclosed: $ __________

Signature: ___________________________________

Date: _________________________________

Make your check payable to FCSC and mail to:

THE FUNERAL CONSUMER SOCIETY OF COLORADO

4101 East Hampden Avenue

Denver, Colorado 80222

How did you hear about the Society?