LA SOCIETÁ ITALIANA, INC. NEW MEMBER FORM (ALL FIELDS WITH AN ASTERISK ARE REQUIRED) NEW MEMBER (#1) INFORMATION *Name: Date of birth *Occupation/Retired: *Current street address: *Heritage: *City: *State: *ZIP Code: SPOUSE/SIGNIFICANT OTHER (#2) INFORMATION IF JOINT MEMBERSHIP Name: Heritage: Date of birth: Occupation/Retired: CONTACT INFORMATION *New Member Cell Phone: *New Member E-mail: Spouse/Significant Other Cell Phone: Spouse/Significant Other E-mail: *Years in Area #1:Years in Area #2: CHILDREN (IF APPLICABLE) Name/Age: Name/Age: Name/Age: Name/Age: *HOW DID YOU HEAR ABOUT THE CLUB? A Friend Told MeInternet SearchSocial MediaGeorgia BulletinOther A Friend Told Me A Friend Told Me Internet Search Internet Search Social Media Social Media Georgia Bulletin Georgia Bulletin Other Other PLEASE DESCRIBE YOUR EXPECTATIONS FOR THE CLUB PLEASE SELECT (X) ANY OF THESE CLUB EVENTS/COMMITTEES TO INDICATE YOUR INTERESTS Committee #1 #2 Membership Checkbox_7 Checkbox_1 Publicity Checkbox_8 Checkbox_2 Cultural/Heritage Checkbox_9 Checkbox_3 Recipe Checkbox_10 Checkbox_4 Web Site Checkbox_11 Checkbox_5 Event #1 #2 La Befana Checkbox_12 Checkbox_17 Columbus Day Checkbox_13 Checkbox_18 Carnevale Checkbox_14 Checkbox_19 San Giuseppe Checkbox_15 Checkbox_20 Board Position (in the future) Checkbox_16 Checkbox_21 Event #1 #2 Annual Picnic Checkbox_22 Checkbox_27 Italian Cooking Checkbox_23 Checkbox_28 Carnevale Raffle Checkbox_24 Checkbox_29 Event Photos Checkbox_25 Checkbox_30 Bocce Ball Checkbox_26 Checkbox_31 DUES CALCULATION AND MAILING INSTRUCTION 1) Annual dues for the Fiscal Year are $60 per person or $120 per couple which includes children who live at home 2) If you join after February 28th please reduce the above Dues amount by 50%, as the Club's Fiscal Year runs from September 1st through August 31st 3) Make your check payable to “La Societa Italiana, Inc.” Please Mail your check to Frank Chillemi, 1785 Lum Crowe Road Ext, Roswell, GA 20075 SIGNATURES (Use Mouse to Sign) Signature of new member: Date:
