Name (Head of the Family)

Spouse Name (Optional) Children’s Name (Optional) All Children’s of above 18 years of age must fill separate membership form.

Gender

• Male
• Female

Children’s Name

Home Address

Number

Zip Code

Suite # (P.O Box)

E-mail

Street

Cell

City

Phone

State

Referred by

Name

E-mail(*)

Cell

Signature (Head of the Family)

Phone Number

Date (MM – DD – YYYY)

I certify that all the information that was provided by me in this form is true to the best of my knowledge. I also hereby authorize Hyderabad Association to publish my name, address, home phone, and cell/work phone on the Hyderabad Association web site and in the Hyderabad Association Directory.

• Yes
• No
• (Optional)

HA USE ONLY

Membership Verification

Membership Number

Total Number of Members

Date of Membership Received

Membership Since

Personal Check / Money order #

Total Membership fee Received $ Received Personal Check / Money order/Cash

Membership Expired Membership Status Good Standing/ Renewal/Expired

Membership form and dues Received by

Signature

Date

Annual Membership Amount: Please Select Membership Plan Family Membership - 50.00 USD Senior Single - 20.00 USD Single Membership - 30.00 USD Senior Citizen Couple - 35.00 USD Student Membership (over 18 years of age) - 20.00 USD Donation - 10.00 USD Life time Membership - 100.00 USD