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MEMBERSHIP APPLICATION FORM

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TITLE(S): Ms. Mrs. Mr. Mr. & Mrs.

Name(s):

__________________________________________________________________

Address:

__________________________________________________________________

City:________________________ State:_____ Zip:_________________________

Phone (Home):____________________ Phone (Work):______________________

____ $15.00 Individual Membership

____ $20.00 Family Membership

____ $25.00 Professional Membership

____ $20.00 Group Homes up to 4 Residents, $5.00 Each Additional Resident

To join and become a member, send your dues to:

The ARC Kenosha County Inc.

1218 79th Street

Kenosha, WI 53143