DOLAN SPRINGS COMMUNITY COUNCIL

2016 MEMBERSHIP APPLICATION

(January 1 – December 31)

Please print when completing the following:

NAME: ______________________________________________________________________

COMPANY (If applicable): _______________________________________________________

MAILING ADDRESS: __________________________________________________________

_______________________________________________________________

TELEPHONE: HOME ______________________ CELL ______________________

EMAIL: ________________________________________________________

I HAVE AN INTEREST IN (PLEASE CHECK):

A. SERVING ON THE COUNCIL BOARD ______

B. HELPING WITH FRIDAY NIGHT BINGO ______

C. HELPING WITH THE COMMUNITY CHRISTMAS DINNER ______

D. HELPING REVIEW THE COUNCIL BY-LAWS ______

E. SERVING ON A COUNCIL COMMITTEE (Please circle): ______

Public Education, Building, Membership, Public Relations, Grant Writing, Fundraising, Community Events Calendar

________________________________ __________________

Signature Date

-----------------------------------------------------------------------------------------------------------

FOR OFFICE USE ONLY

DSCC Signature ______________________________ Date: / /

Check # ________ or Cash __________ Date Received _________________

Receipt issued Y/N _________ Membership card issued Y/N ____________

PO Box 201, Dolan Springs, Arizona, 86441

(928) 767-4252