is a non-profit corporation

P.O. Box 286, Huron OH 44839

E-mail: grassroots@bex.net

Visit us on the Web: www.plan2succeed.org/grassroots

Annual dues: $25.00 (individual)

Name:

_______________________________________________________

Address:

_____________________________________________________

City:

________________________

State:

______

Zip:

_________________

Phone:

____________________

E-mail:

____________________________

(Your personal information will not be shared with other organizations; your

E-mail address will be used to send you updates and our monthly

newsletter.)

Participation in Committees (see Organizational Chart):

Investigative

___________________________________________________

Public Relations

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Policy

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Fund Raising

__________________________________________________

Membership

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Housekeeping & Event __

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Other (specify):

_________________________________________________

____________________________________________________________

Signature: _______________________________ Date: _______________

Please, send us your most generous donation (make check payable to

)

$25.00

$50.00

$100.00

$200.00

Other: $_____________

(Donations are not Tax deductible.)

To be filled by GAV member sponsoring membership*

Sponsored by: _____________________________ Status: _________________

Final acceptance is subject to approval by the Members of the Board of Directors *