Membership Application Form

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NAME:         _________________________________________

ADDRESS:    _________________________________________

CITY:           ___________________________________________

STATE:        __________________________________________

PHONE #     __________________________________________

EMAIL ADDRESS       ____________________________________________________

PLEASE CHECK ONE:

GUIDE DOG USER        __                REG.  PRINT      ______

FRIEND                         __                LRG. PRINT      ______

FAMILY                         ___              BRAILLE           ______

SUPPORTER                ___               DISK                 ________

Thank you for your interest in DixieLand Guide Dog Users.  Our annual membership dues are $10, which automatically enrolls you as a member of the national organization, GUIDE DOG USERS, INC.  Please make your checks payable to:

DIXIELAND GUIDE DOG USERS

Send your completed application form and check to:

PATSY JONES, TREASURER

1822 BURNHAM STREET

WEST COLUMBIA, S.C. 29169

We appreciate your support and look forward to meeting you personally.

Sincerely,

Audrey Gunter, President