YEAR 2012 - MEMBERSHIP DUES - $25.00

PLEASE PRINT THIS PAGE AND COMPLETE THE FOLLOWING INFORMATION:
(USE ONE SHEET PER MEMBER)

Check one: [ ] RENEWAL [ ] NEW MEMBER

NAME ______________________________________________________________

MUNICIPALITY/COMPANY ______________________________________________

TITLE ______________________________________________________________

MAILING ADDRESS ___________________________________________________

CITY, STATE AND ZIP CODE ____________________________________________

PHONE NUMBER (WITH AREA CODE) _________________

FAX (WITH AREA CODE) ______________

E-MAIL ADDRESS _____________________________________________________

MAKE CHECKS PAYABLE TO: NORTHERN OHIO SERVICE DIRECTORS ASSOCIATION
MAIL THIS FORM AND YOUR CHECK TO:

City of Pepper Pike
28000 Shaker Boulevard
Pepper Pike OH 44124
Attention: Bob Girardi

WE ARE REQUESTING THAT YOU RETURN THE ENTIRE ORIGINAL FORM WITH YOUR MEMBERSHIP DUES TO INSURE PROPER CREDIT.
MAKE A COPY FOR YOUR RECORDS. THANK YOU

2012 N. O. S. D. A. MUNICIPAL MEMBERSHIP DUES - $25.00