PO Box 8095
Moscow, ID 83843-8095
Name: ___________________________________________________________________________________
Address: _________________________________________________________________________________
City, State and ZipCode: _____________________________________________________________________
Email Address: ____________________________
Bithdate: (month/day) ________________________ 20's, 40's, 60's etc. ________________________
Contact: Home _____________________________ Work ____________________________________
Brief description about yourself:
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Likes and Dislikes:
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Hobbies and Interests:
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Palouse Area Singles and it's members will not be held responsible or liable for any injuries, accidents or property damaged to the undersigned, and to any person or property in connection with any group function. Palouse Area Singles, known as PAS, has the right to cancel any application or membership at any time.
Signed:______________________________________________________Date:_________________________
Information provided will be included in the membership directory. However, optional information(s) like address
or telephone number which you wish to remain confidential, please put an asterisk (*) mark by it. It will not
be published and will only be used for mailing purposes.
