Order of Southern Gray

“Women Dedicated to Southern Heritage”

Membership Application
(Please print this form, complete it and mail to address below)

Name_____________________________________________________

Address___________________________________________________

City___________________________________ State/Zip_______________________

Home Phone______________________ Work Phone___________________________

E-mail______________________________ Birth date____________________________

Reason/s for joining: ____________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________

Type of membership (circle one):
Regular ($20)   Associate (child) $10

Chapter Affiliation: _______________________________________________
(If you will not be affiliated with a chapter at this time, leave this line blank.)

Mail application and dues to:
Carol Martin, Vice President
8030 Pine Stake Road
Rhoadsville, Virginia  22542
Phone: 540-854-4015