IN ORDER TO SUBMIT APPLICATION FOR MEMBERSHIP IN TRI-CITY SAMS YOU MUST BE A MEMBER IN GOOD STANDING WITH THE INTERNATIONAL GOOD SAM CLUB.

YEARLY DUES FOR TRI-CITY SAMS IS $20, PAYABLE WITH YOUR APPLICATION. THEY ARE DUE EVERY OCT.1ST FROM THEN ON.

NAME:___________________________________________________

ADDRESS:________________________________________________

PHONE#__________________________________________________

INTERNATIONAL GOOD Sam#_________________________________

EXPIRATION DATE:_________________________________________

NAMES OF OTHER DEPENDENTS AT Home: __________________________________________________

PLEASE FILL IN APPLICABLE BLANKS AND RETURN FORM TO:

Kenn Latal

Pine Ridge Estates
1737 US RT 9W #89
SELKIRK,NY 12158:

Make dues check for $20.00 payable to Kenn Latal.

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