Address: _______________________________________________________
City: ___________________ State: _______________ Zip: ______________
Home ph#: __________ Birth mm/dd ______ Nick Name: _______________
Work ph#: __________ Fax: _________ Email: ________________________
Occupation: _____________________________________________________
I am interested in the following activities: (Please circle all that apply)
Parties Phone committee
Community Service Membership cmmittee
Newslwetter Fund-raising committee
How did you hear about the club? ___________________________________
If we do a phone list or directory, is it okay to print your name/address/email/phone? YES NO
Interesting Facts: Do you have a most interesting comcert, furthest traveled, or large number of concerts attended fact to share with the club?
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The Obligatory Fine Print
* Each member of the Cincy PHC is responsible for his or her own actions and behavior whether
negative or positive.
* Membership in the club does not give the member permission to use Jimmy Buffett's name, song
titles,lyrics, names of business or other trademarked, copyrighted, or reserved material owned by
Jimmy Buffett. Nor can any member use the logo of the Cincy Parrot Head Club, Inc., or Parrot
Heads in Paradise, Inc.
** Annual dues are $24/person
Make checks payable to: Cincy Parrot Head Club
MAIL TO: CPHC
P.O. Box 1
Loveland, OH 45140
These dues are not deductible as charitable donation for fed, state or local tax purposes.