Arkansas State Society of Washington D.C. |
| Name of Arkansan: | |
| Name of Spouse/Partner: | |
| Arkansan's Home: | |
| Spouse/Partner's Home: | |
| Arkansan's Alma Mater: | |
| Spouse/Partner's Alma Mater: | |
| Arkansan's Office Phone: | |
| Spouse/Partner's Office Phone: | |
| Local Phone Number: | |
| Local Street Address: | |
| City, State, Zip: | |
| Names of Children: | |
| Fax Number: | |
| Arkansan's Email Address: | |
| Spouse/Partner's Email Address: |
| Enclosed find: | For Office use only: |
| ___ $40 for Individual | Membership No. ________ |
| ___ $50 for Family/Couple | __ New __ Renewal: |
| Please return this form along with a check made payable to the Arkansas State Society. | |
| Arkansas State Society 4000 Cathedral Avenue, NW Box 631-B Washington, DC 20016 |
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