Membership Application Form

Membership Application

To apply for membership (or to renew an existing membership) please complete all questions. The membership year runs from January to December. No prorations are made for payments made after January.
You must provide an e-mail address and pay by PayPal to use this form. To obtain a paper form and pay by check or cash, please contact us (see below) or pick one up at our next meeting.
Name *

First NameLast Name
Name (if applying as a couple)

First NameLast Name
Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip CodeCountry
E-mail*
example@example.com
Telephone Number
Comments or Additional Information
Which year are you paying for? *
Contact us: Kyndall Potts (Exchequer) 614 296 2730 or email us at AgraTreasurer@gmail.com

Visit our website: www.agratreasurers.net

The Agra Treasurers is tax-exempt under Section 501(c)(3) of the Internal Revenue Code. No products are services are provided in exchange for membership dues, and they may be tax-deductible as a charitable contribution. Tax ID # 61-2067628
My Products
prevnext( X )
Single
$10.00

Couple
$10.00
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