Downtown Sertoma Club of Chattanooga

Membership Application

Name ____________________________________________________________

Occupation _______________________ Job Title _____________________

Birthday / / Spouse _______________________

Recruited By ____________________________________________________________

Home Address ____________________________________________________________

____________________________________________________________

Home Phone _______________________ Home Fax ____________________

Home E-Mail _______________________

Employer ____________________________________________________________

Work Address ____________________________________________________________

____________________________________________________________

Work Phone _____________________ Work Fax ____________________

Work E-Mail _____________________

Preferred Mailing Address: Home Work Preferred E-Mail: Home Work

Have you ever been a Sertoman before? Yes No

Please circle one of the following: New Member Rejoining This Club

Transfer From Sertoma Club

Complete this form and bring it to a Club Meeting at the Choo Choo, or mail it to: Downtown Sertoma Club of Chattanooga

P. O. Box 11042

Chattanooga, TN 37401-2042

Signed ___________________________ Date _____________________________