Mail form and payment to:
Linda Cepela
Po Box 263
Rutland, Vt 05702-0263
_______________________________________________________________________________
Print (clearly please), fill out and mail
DATE:_________________________________________________________________________
NAME:________________________________________________________________________
ADDRESS:__________________________________________________________
CITY:______________________STATE:_________________ZIP:______________
EMAIL:_____________________________________________________________
PHONE:________________________________DOB:________________________
Comments:_________________________________________________________
___________________________________________________________________
___________________________________________________________________
Please allow 4-6 weeks for your packet
___________________________________________________________________
Office Use Only
Membership Number___________________
Payment Received_____________________
Packet Mailed_________Date____________
