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May / June 2006 – Volume XIV – Issue IX - page 17 / 32

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Application For Membership To The Parrot Head Club Of Eastern Massachusetts

Date: ______________________________

Single membership ($20): Family membership ($25): (1 address)

Name (1): ___________________________

Name (2): ___________________________ (include keets as appropriate)

Address:

____________________________

WWW.PHCOEM.COM

_ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _

E-mail (1):

__________________________

Birthday: ______________________

E-mail (2): __________________________

Birthday: ______________________

Phone:

_ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _

Occupation: _______________________________________________________

Favorite Buffett song:________________________________________________

Other important dates we should know about:_______________________________

Any special skills you’d like to share with the club:

____________________________

How did you hear about PHCOEM:________________________________________

Closest I came to meeting Buffett:

_______________________________________

_________________________________________________________________

Note: memberships are renewable annually. Make checks payable to PHCOEM and mail to: PHCOEM, PO Box 508, Milton, MA 02186 Contact Jim Spaulding, 781-293-2169 (Jim1955@aol.com)

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