Membership / Donation Application

National Indo-American Association for Senior Citizens, Inc.

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Name______________________________ Telephone # (____)____________ Fax # (____)____________

Address____________________________________________________Zip___________________

Email____________________ Sex: Male__ Female __ Age: 50 years or older___ Under 50 years___

Please check one: ___Individual Membership ___Organization Member
Please check one of the following

Regular member (50 years and over) ... ___$10.00 per year ..........___$40.00 for 5 years......$100.00 Life membership
Member under 50 years (non voting) ...___$10.00 per year .........___$40.00 for 5 years.......$100.00 Life membership
Not for profit organization....................___$100.00 per year ..........___$400.00 for 5 years
Other agencies/institutions............ .....___$100.00 per year ..........___$400.00 for 5 years

I, __________________, have read the goals and objectives of the Association and I shall subscribe to them:

* I am interested in volunteering my services___........................Signature:______________________

Any additional donation would be highly appreciated.
Please check the donation amount

____$50.00 .____$100.00 .____$200.00 .____$250.00 .____Other (Please specify)________

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Please make check payable to National Indo-American Association for Senior Citizens or NIAASC and mail to 895 David Walker Drive, Tavares, FL 32778