Statement of Dues
2007 - 2008
Dues
are due and payable by August 1:
Dues are delinquent after August 30. A reinstatement late fee of $5.00 will apply after that date.
Club Name:____________________________________________________
When
does your Club meet:_______________________________________
Where
does your Club meet:______________________________________
Month
of Annual Election of Officers:______________________________
Year
Club was formed:___________ Year Club joined
State:____________
Club
President:_________________________________________________
Mailing
Address:_______________________________________________
_______________________________________________
_______________________________________________
(City) (State) (Zip Code)
Telephone: (________)____________________________
Email:__________________________________________
State
Representative:____________________________________________
Mailing
Address:_______________________________________________
_______________________________________________
_______________________________________________
(City) (State) (Zip Code)
Telephone: (________)____________________________
Email:__________________________________________
Assessment: Annual dues are $4.00 per capita. Please include (3) copies of your membership list with the names, addresses (including city, state, & zip codes) with this form. An additional $5.00 club fee is required for first time or re-instated clubs.
Current
Number of Paid Members: ____________
Amount
of Check: $____________
Make Check payable to: Wisconsin Organization of Mothers of Twins Clubs or WOMOTC
Mail this form, copies of Diane Baillargeon , Treasurer
Membership & payment to:
Payment Received from:______________________________________________
Amount: $______________ Date:_____________________