INDIVIDUAL / FAMILY MEMBERSHIP APPLICATION
Personal Information
Name:
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Date of Birth:
*
Spouse/Partner:
Date of Birth:
Mailing Address:
*
Email:
*
Phone:
*
Employment Information
Employer:
Occupation:
Business Address:
Email:
Work Phone:
What are your three main areas of interest for the Hispanic Community?
1
2
3
What Committees are you interested in helping with?
Education/Scholarship:
Events:
Fundraising:
Volunteer:
Community Action:
Other:
Individual / Family Membership
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Individual Membership for One Year ($50 USD)
Family Membership for One Year ($80 USD)
Authorized Applicant Signature:
*
Date:
Monday, 12 May 2025 (EDT)
Name:
Type your name to sign this document:
Typing name is equivalent to a handwritten signature
Scan this QR code with your phone:
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