Blohards Membership Form

Please return to:

BLOHARDs
C/o Julie Powers Killian
42 Forest Ave.
Rye, NY 10580

Name:	____________________________________________
Address:	____________________________________________ ____________________________________________
Phone:	____________________________________________
Email address:	____________________________________________

Dues type:	Annual ($20)	Paid by:	Cash
	Lifetime ($150)		Check
			Credit card

_____________________________________________________________________________
Official Use Only

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