Membership Application      Variety of Georgia - Tent 21
Please print this page and mail or fax the completed form to our office.

NAME _____________________________________ DATE OF BIRTH _____________

HOME ADDRESS _______________________________________________________

CITY _______________________________ STATE _____  ZIP ___________________

HOME PHONE ______________________ HOME FAX _________________________

COMPANY NAME _______________________________________________________

COMPANY ADDRESS ___________________________________________________

CITY _______________________________ STATE _____  ZIP ___________________

WORK PHONE ______________________ WORK FAX _________________________

NATURE OF BUSINESS __________________________________________________

PREFERRED EMAIL ADDRESS ____________________________________________

PREFERRED MAILING ADDRESS       HOME ___ OFFICE ___

"The Variety Oath"
In applying for membership to Variety of Georgia, Tent 21, I understand and accept the precepts and objectives of Variety in its efforts to aid and improve the quality of life of needy and handicapped children ... and to commit myself to the fulfillment of this cause. I will, to the best of my ability, put forth my best effort on behalf of Variety of Georgia, Tent 21, and the children's charities we support.

______________________________________________         ________________
              Signature of Applicant                                                                         Date

APPLICANT --- PLEASE DO NOT FILL IN BELOW

Date Application Filed __________ Sponsored by: ______________________________

Approved by Membership Committee:     Date ___________________

Chairman  ______________________ Chief Barker __________________________

Variety of Georgia, Tent 21         Mike Simonds, Executive Director     
9800 Medlock Bridge Rd., Suite 1   Johns Creek , GA 30097   Telephone 678-994-4210