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− | '''Name:''' |
+ | '''Name:''' __________________________________________ |
'''Address:''' _________________________________________ |
'''Address:''' _________________________________________ |
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+ | '''Applicant Signature:''' ___________________________________ '''Date:''' ____________ |
Revision as of 22:35, 15 October 2014
Name: __________________________________________
Address: _________________________________________
_________________________________________________
_________________________________________________
Phone number: _________________________
Email address: ___________________________________
Initial each of the following:
______ I have read and agree to abide by the Dayton Diode Charter.
______ I have read and agree to abide by the Membership Agreement.
______ I have signed the Liability Waiver.
Applicant Signature: ___________________________________ Date: ____________
Officer Signature: _______________________________________ Date: ____________
Licensed under Attribution-Noncommercial-Share Alike 3.0 Unported based on the Hive 13 Membership Application
Consensed on by Dayton Diode membership on Nov 2, 2010.