SAMPIGE
Triangle Kannada Association

Membership Form for 2008

Renewal ___ New Membership ___    Date ___________

Member Name: ___________________  ______________________
                     (Last)        (First)
Spouse Name: ___________________  ______________________
                     (Last)                (First)
Address:     __________________________________________________

             __________________________________________________

Phone: (____) ____ - _______

eMail: _________________________________________________

Children:      Name           Sex Age  Date of Birth
1. __________________________ M/F ____ ______________
2. __________________________ M/F ____ ______________
3. __________________________ M/F ____ ______________

 
Annual Memberships:   Family: $35.00, Single: $15.00, Student: $10.00

Life Membership: $250.00
Donation: $______
Amount Enclosed: $_____ Check No: ______

Please make check payable to "Sampige". Mail the check along with the Membership Form to:
Sampige
P.O.Box 1201,
Morrisville, NC 27560-8711