MEMBERSHIP APPLICATION

                        JANUARY – DECEMBER

                                                    

                                                           Please check one of the following membership levels

                                                                               $24.00/year FULL FAMILY MEMBERSHIP

                                                             $10.00/year FRIENDS OF KOI CLUB                                     

                                                                               $100.00/ year CORPORATE MEMBERSHIP

^{LAST NAME}                 

^{FIRST NAME}                

OTHER FAMILY MEMBERS YOU WOULD LIKE INCLUDED

WITH THIS MEMBERSHIP - IMMEDIATE FAMILY ONLY

^{SPOUSE OR SIGNIFICANT OTHER}  

^CHILD

^CHILD

^CHILD  

^CHILD

^ADDRESS

^{CITY / STATE / ZIP} 

^{HOME PHONE}

^{CELL PHONE}

^{E-MAIL ADDRESS} 

      

Do you want your e-mail address available to MEMBERS ONLY on the website? YES    or NO

 

PLEASE HIT THE SUBMIT BUTTON BELOW

TO COMPLETE YOUR APPLICATION