Registration Form

Name: ____________________________________________________________

Address: __________________________________________________________

Telephone: (Daytime) ______________ (Evening) _______________ E-Mail: ____________

Member's Relative(s):

Name: __________________________________________________

Address: _________________________________________________

Telephone: ______________

General Situation/Information Needs (Optional): ____________________________________________

_____________________________________________________________________________________

_____________________________________________________________________________________

Please mail this form, with your preferred form of payment, to:

_____ I have enclosed a check for $52 for my one-year membership

_____ Please charge my MasterCard/Visa # ________________________________________________

.............Expiration Date: __________ ...Signature .__________________________________________

____ Please send me more information about SeniorLink.