2008 Membership Form

Name(s) Date

Mailing Address

City State Zip

Home Phone Work Phone Cell Phone__

E-mail Address

Check the Appropriate Membership Category:

Household ($75) Individual ($50) Student (low income) $25

Specify up to three social concerns about which you feel passionately and which you would be willing to work with other MFSA members to address:

(1)

(2)

(3)

Make checks payable to Florida MFSA and mail to: Robert Thomason, Membership Secretary

2 Ocean Dune Circle

Palm Coast, FL 32137

(386) 446-8066

rthomason@cfl.rr.com

Dues are divided between the Florida Chapter and National MFSA as follows: Household (60/15); Individual (40/10); and Student (low income) (20/5)