YOUR NEEDS AND POCKETBOOK BEST!
THERE'S A MEMBERSHIP THAT'S JUST RIGHT FOR YOU
MAINE AQUARIUM
12 MONTH MEMBERSHIP APPLICATION FORM
(please check one)
MAINE
AQUARIUM $10.00____
INDIVIDUAL "STUDENT"MEMBERSHIP
(name of school_____________, city____________ GR.____)
MAINE AQUARIUM $15.00 ___
INDIVIDUAL "SENIOR CITIZEN" MEMBERSHIP
(date of birth required for senior citizen discount_/_/_/
)
MAINE AQUARIUM $25.00 ___
"INDIVIDUAL" MEMBERSHIP
MAINE AQUARIUM $48.00 ___
"FAMILY" MEMBERSHIP
(family membership includes both parents and all
children through 18 living in the same household)
MAINE AQUARIUM $48.00 ___
"GRANDPARENTS" MEMBERSHIP
(grandparent membership includes up to 2 grandparents
and up to 4 grandchildren through 12 years of age)
(please check) ___NEW ___RENEWEL ___GIFT
Members
Name:(last)____________(first)_________(MI)___
Spouses name:__________________________________
Street Address:________________________________
City:_________, State:_________, Zip:__________
CHILDREN'S NAMES AND DATE OF BIRTH:
________________ _____________
________________ _____________
________________ _____________
________________ _____________
AMOUNT REMITTED $________ CHECK
#_______
(DO NOT SEND CASH)
MC/VISA/AMEX/DISCOVER (Circle one)
ACCOUNT#____________________EXP.DATE_______
SIGNATURE__________________________________
TODAYS DATE:________________
If this membership is a gift would you
like us to mail the new membership card to you?( Y or N )
or to the new members(s) ( Y or N )?
Please print your name and address on the below line so
we can credit you.
(NAME)_____________________________________________________
PRINT THIS OUT AND MAIL TO:
MAINE AQUARIUM MEMBERSHIP
YOUR MEMBERSHIP CARD
WILL BE MAILED TO YOU PROMPTLY