For
Membership Information, you may contact us at
dalymk@aol.com
or return this application
to us (see address below)
PHINS Parrot Head Club, Jacksonville, Florida
Membership
Application
$30 Family
Membership _______ $20 Single Membership _______
CHECK # ________ CASH ________ Date
Paid ____________
MEMBER NAME(s): _______________________________________________
ADDRESS: __________________________________________ZIP__________
PHONE NUMBERS: (HOME) ______________________________
(WORK) __________________ (CELL) _____________________
E-MAIL Address__________________________________________
DATE(s)
OF BIRTH (Month and Day) _________________________
PARAKEETS
NAME: ___________________________________DOB:__________
NAME: ___________________________________DOB:__________
NAME: ___________________________________DOB:__________
NAME: ___________________________________DOB:__________
Please bring
this form to a Social PHlocking at Lillian’s
First Wednesday of each month or mail to:
PHINS
c/o Marilyn Daly
1539 Derringer Rd. Jacksonville,
Fl 32225
