Omaha Nebraska Parrot Head Club - New Membership Application

Dues are as follows:

· Single applications are $15.00. Joint memberships are $20.00

Is this a new single or joint membership? ______________

Name: ___________________________________________________________________________________

Address: _________________________________________________________________________________

City: ______________________________________ State: ______________________ Zip: ____________

Home Phone: _________________________________Work Phone: ________________________________

E-mail Address: ___________________________________________________________________________

Birth date: _________________________ Occupation: ______________________________________________

Favorite Buffett song: _________________________________________________________________________

How did you hear about us? ______________________________ Referred by: ___________________________

Check all of the areas where you would be willing to help:

Newsletters Recruiting Public Relations Social events Service projects I just want to party

Second Applicant information for joint memberships:

Name: ___________________________________________________________________________________

Address: _________________________________________________________________________________

City: ______________________________________ State: ______________________ Zip: _____________

Home Phone: _______________________________ Work Phone: __________________________________

E-mail Address: _____________________________________________________________________________

Birth Date: _________________________ Occupation: ______________________________________________

Favorite Buffett song: _________________________________________________________________________

How did you hear about us? _____________________________ Referred By: ____________________________

Check all of the areas where you would be willing to help:

Newsletters Recruiting Public Relations Social events Service projects I just want to party

I would like the Beak’n Newsletter in: _____ paper form _____ e-mail form ______ both

Make checks payable to: OMAHA NEBRASKA PARROT HEAD CLUB(ONPHC)

Mail this application and check or money order to:

Frank Siedlik

16824 Pierce St. Date Paid ____________ Check # _____________ Amount ___________

Omaha, Ne. 68130

Now the disclaimer: The state incorporation of the Omaha Nebraska Parrot Head Club requires that members be at least 21 years old. This contribution is NOT deductible as a charitable contribution for tax purposes.