Lancaster Sertoma Meets 1st Thursdays & 3rd Thursdays
at 5:30PM at the Tennis & Yacht Club

Membership Form

I hereby make application for membership in the Sertoma Club.

Prefix:

*First Name:

MI:

*Last Name:

ADDRESS

*Street

*City

*State

*Zip

CONTACT INFORMATION

*Home Phone

*Mobile

Fax

*Email

Date of Birth

Spouse

BUSINESS INFORMATION

Name of Business:

Position Title:

Business address:

City:

State:

Zip:

Please check the manner in which you would like to receive correspondence:

Business AddressResidence AddressEmailFax

Recruited by:

This application is accompanied by $ in payment of the membership Fee. I understand that I will be responsible for dues and I agree to abide by the provisions of the Club Constitution and By-Laws.

Date:

Applicant's Signature:

TYPE OF MEMBERSHIP

CharterActiveTransferReinstatedTransfer/LifeReinstated/LifeCorporate