Welcome To Gujarati Samaj Of Saint Louis

*Please fill this form and send the printed copy along with your check to the address below.

Name:	Last:		First:
Spouse:	Last:		First:

Dependents:

Name:		Year Born:
Name:		Year Born:
Name:		Year Born:
Name:		Year Born:

Home Address:

Street:
City:
State:		Zip:

Telephone Numbers:

Home:
Work:
Cell:
E-Mail:

Membership: check one of the below.

         $50 - One year Family Membership
         $30 - One year Individual Membership
         $10 - One year Student Membership
         "Life membership is not available this year".

Note:

	Family Membership is limited to husband, wife and children under age 21.
	One year membership is good from January till December.
	Please make your check payable to "Gujarati Samaj of St. Louis" and send it along with this form to

Jitendra Parbhu
2577 Hidden Meadow Ln.
St. Louis, MO. 63021