FCA of S/MC - Form

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I hereby apply for membership in the Funeral Consumers Alliance of Stanislaus / Merced Counties. Please send me the INSTRUCTION SHEET which I will fill out and return promptly along with a check for the membership fee. The membership is for life unless I request to withdraw from membership. I understand that membership fees are non-refundable. Gifts are always welcome. They may be “in memory” or “in honor” of someone I name. I am printing to ensure legibility.

Name: ___________________________________ Date: ______________

Mailing address: _______________________________________________

City/State: ____________________________________________________

Zip:______________________ Phone:_____________________________

My email address:_____________________________________________

I’m agreeable to receive our newsletter by email to save postage. (Y) (N)

Children under 18 to become members (Names & Dates of Birth):

Name:___________________________________ DOB: _______________

Name:___________________________________ DOB: _______________

Name:___________________________________ DOB: _______________