Shomrim Society of Illinois
P.O. Box 59258 Chicago, Il 60659
2009 Membership
Application
PLEASE RETURN THIS FORM WITH A CHECK or MONEY ORDER
FOR
THE APPROPRIATE AMOUNT OF YOUR MEMBERSHIP DUES
PAYABLE
TO: Shomrim Society
WE NEED ALL OF THE REQUESTED INFORMATION
Application
Type (circle one)
Renewal
New Member (sponsored by _______________________________)
Regular $20.00
Associate $20.00
Retired $10.00
Honorary $50.00
Lifetime Honorary $500.00
Regular Life
Presidential Life
Honorary Life
………………………………………………………………………………………..…………………
PLEASE PRINT LEGIBLY
Name
_________________________________________________ Date of Birth _______________________
Address __________________________________________________________________________________
City __________________________________________ State
_______________ ZIP ___________________
Home Phone ______________________________ Work Phone _____________________________________
E-Mail _____________________________________________________
Beneficiary ____________________________________________
Relationship ________________________
Beneficiary
Address ________________________________________________________________________
City __________________________________________ State _______________ ZIP
___________________
Agency Employed By ______________________________________________
Full / Part -time (circle one)
Rank / Position _____________________________ Star / Badge # ___________
Assignment ____________
Children’s, step-children’s
or grandchildren’s names & ages ________________________________________
_________________________________________________________________________________________
_________________________________________________________________________________________
I am applying
for membership or renewal of membership in the SHOMRIM SOCIETY OF ILLINOIS ENDOWMENT FUND, INC. The information I have provided
on this application is true and complete to the best of my knowledge.
Signature _________________________________ Date ________________
--------------------------------------------------------------------
BOARD USE ONLY -----------------------------------------------------------------
Date approved (new member only)
_________________________________Check # _________________________________ Amount Paid _________________________
Date rcvd _____________________
