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MakeChecks Payable to: THE CHAPTER 146 ASSOCIATION
90 GREAT WOODS RD., SAUGUS, MA 01906
EMAIL US THAT YOU SENT YOUR APPLICATION IN
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CIRCLE ONE |
How did you pay? Check or Cash…? |
Total Donation
______________
+ ______________
+ ______________
= $ ____________
MAKE COPY |
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Renewal
Membership |
New
Membership |
CHECK # _______________ |
$CASH$ |
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Today’s Date |
Donation
$ |
Back Dues
$ |
146 Membership Dues (CIRCLE ONE) |
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1 Year
$25 |
2 Years
$50 |
3 Years
$70 |
4 Years
$90 |
5 Years |
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$100 |
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* MAKE COPY FOR YOUR RECORDS * PRINT CLEARLY IN ALL CAPITALS ONLY *
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LAST NAME: |
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FIRST NAME: Nick Name: ________________ |
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HOME PHONE: CELL: WORK:
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Employer:________________________________________________________________________________,
Title:____________________________,Licens(s) :___________________Union:_______________
Address:________________________City:_____________ State:____ ZIP:______
Your MASS State Legislators: Sen._________________,Rep.___________________ |
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Chapter 146 Association Records Only
Treasure’s Initials:___________Secretary’s Initials:_____________Membership Expires:________ |
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