AUXOP ASSOCIATION

NINTH DISTRICT

MEMBERSHIP APPLICATION

PLEASE PRINT

NAME _____________________________________________________MEMBER # _________________

ADDRESS ___________________________________________

CITY ____________________________STATE _________ ZIP CODE _________________

PHONE: HOME ______________________________ BUSINESS ____________________________

SPOUSE NAME ________________________________________

AUXILIARY ENROLLMENT DATE ____________________ PROCTOR (Y) (N)

AUXOP CERTIFICATE DATE _______________________

AUXILIARY OFFICES: HIGHEST HELD ___________________ CURRENT __________________

QUALIFICATIONS: _____VE _____INSTRUCTOR _____ CREW _______COXSWAIN _____MDV

DUES: DUE THIS PERIOD ______________________ $5.00

INITIATION FEE ________________________$5.00

DUES COLLECTED EVERY TWO YEARS ________$5.00

AUXOP ASSOCIATION BLAZER PATCH ________$4.00 TOTAL $__________

MAKE CHECK PAYABLE TO: AUXOP ASSOCIATION 9CR

MAIL TO: Ken Larson SEC/TREA.

18424 Iroquois Lane
Millersburg, MI 49759

For Office Use: Dues ________________ SENT: Certificate_____________

Initiation Fee ______ Member Card ______________

Patch _______________ Patch ____________________