Shomrim Society of Illinois                P.O. Box 59258    Chicago, Il  60659

Membership Application

PLEASE RETURN THIS FORM WITH A CHECK or MONEY ORDER

FOR THE APPROPRIATE AMOUNT OF YOUR MEMBERSHIP DUES

PAYABLE TO:  Shomrim Society

SEND TO:  ADDRESS LISTED ABOVE

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

…………………………………………………………………………………………………..

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 _____________________