NOTE: 1) Print this blank form and fill it out with a pen (preferably blue)
2) * - Required Field: This information is required in order to complete membership application.
*TYPE: ___NEW ___RENEWAL ___UPDATE
___Individual ___Family (w/Children) ___Single Parent (w/Children) ___Couple ___Senior Couple (62 & above)
*PRIMARY MEMBER NAME:________________________________________ DATE OF BIRTH:________________
*If applying for a Family, Single Parent, or Couple membership, please provide the name of your spouse, children, and
other family members below:
NAME RELATIONSHIP DATE OF BIRTH
__________________________________________________ ___________________ ________________________
__________________________________________________ ___________________ ________________________
__________________________________________________ ___________________ ________________________
__________________________________________________ ___________________ ________________________
__________________________________________________ ___________________ _______________________
__________________________________________________ ___________________ ________________________
*ADDRESS:_______________________________________________________________________________________
PHONE: Home:_________________ Cellular:__________________ Work:________________Fax:_________________
EMAIL:________________________________________________
Would you like to support our organization by volunteering your time? Before you answer, please click Volunteer Info:
____YES ____NO
If so, would you be interested in any of the following committees? (Please check one or more committees below)
___Membership ___Performing Arts & Fundraising ___Food & Concession ___Ways & Means ___Decoration
___Education & Athletics ___Other (specify)___________________________________________________________
*ANNUAL MEMBERSHIP DUES: (Due on January 1st of each year)
___Individual - $15 ___Family (w/Children) - $25 ___Single Parent (w/Children) - $20 ___Couple - $20
___Senior Couple (At least one is 62 & above) - $15
*SIGNATURE:_______________________________________________________ DATE:_______________________
By my signature, I understand and abide by all the by-laws of PASA. I also understand that my information on this form
will be used exclusively for PASA and will not be shared with outside parties. Liability: I hereby expressly, voluntarily,
and willingly assume all risks associated with my, my spouse�s, and family�s participation in any PASA activity/event.
*Please sign and date, and mail this completed form with your membership dues to this address:
Philippine-American Society of Austin
P.O. Box 270048
Austin, TX 78727-0048 Form rev. Feb., 2006