Minnesota senior sports association
501c3 non-profit Minnesota corporation
APPLICATION FOR MEMBERSHIP


_________________________________________________________________________________
Last Name                                             First Name                                                   Middle Initial

_________________________________________________________________________________
Address

_________________________________________________________________________________
City                                                        State                                                            Zip Code

_________________________________________________________________________________
Home Phone                                         Work Phone                                                Mobile

_________________________________________________________________________________
EMail Address                                                                                                           Fax

_________________________________________________________________________________
Date of Birth (mo/day/yr)

_________________________________________________________________________________
Occupation

_________________________________________________________________________________
2 Yr. Membership ($25)                    5Yr. Membership ($50)                      Lifetime Membership ($100)

_________________________________________________________________________________
Signature                                                                                                      Date