Name:

Current Address:

City, State, Zip:

Home Phone:

Cell Phone:

E-Mail:  

Birthday:                                 

Past Offices or Committee Positions Held:

Husband’s Name:

Children’s Names & Ages:

Special Interests / Hobbies / Occupation:

                Annual Dues:  $25.00                           Make check payable to:

         Seniors (over 60):  $12.50                                          HVWC

Mail completed form and membership dues to:

Debra Rains

4504 Mahogany Lane

Copper Canyon, TX  75077

Would you like a HVWC shirt or sweatshirt?

Shirt (long sleeve denim with logo on left)  $22  S   M   L  XL     $24     2X  3X

Sweatshirt (white with logo on left)             $16     S  M  L  XL    $18    2X  3X

FOR MEMBERSHIP USE ONLY:

Date:  _________    Check# ___________    Cash:  _________Picture ________