IKEBANA INTERNATIONAL    ---    SUN CITY CHAPTER 167

DUES   are payable now for the year 2010-2011


Please list current information, even if there is no change from last year.

This is to insure our Yearbook and Membership information is correct.


_______________________________________________
Last Name            First Name      Telephone number (with area code)


_______________________________________________
Address                                City, State, Zip


_______________________________________________
E-Mail                                Cell Number (with area code)


___________________________________________                                                          
Summer Address                        City, State, Zip


___________________________________________                                                          
Summer Phone (with area code)            Dates at Summer Address

Make check payable to:      I.I.  Chapter #167

Tomodachi  -  $25        Ikebana International/Tomodachi  -  $85

Can be mailed to:  Kazuko Hess, 15816 W. La Paloma Dr., Surprise, AZ 85374
PERMISSION:  Photos are taken at various I.I. events and reproduced in sanctioned publications or at our official website.  Please indicate your preference by checking the appropriate box and sign below.

O  I authorize photo reproductions

O  I DO NOT authorize photo reproductions

Signature  ________________________________

*********************************************************************
For Office Use Only:

Amount Paid:  ________   Check Number: ________  Cash: ________ 


Date Paid: ___________________