PLEASE PRINT ALL INFORMATION

FIRST NAME: LAST NAME:

(NOTE: THIS IS THE WAY YOUR NAME WILL APPEAR ON BADGE # 1.)

SPOUSE’S NAME:

(NOTE: THIS IS THE WAY YOUR NAME WILL APPEAR ON BADGE # 2.)

ADDRESS:

CITY/STATE/ZIP:

HOME PHONE: FAX: E-MAIL:

Do you have a layout? YES NO Under Construction

IF YES, INDOOR OUTDOOR

Are you interested in a clinic on electrical, model building, train layout design or another subject?

YES NO If yes, indicate your interest:

Would you be willing to host an open house? YES NO

NAMES TO APPEAR ON ADDITIONAL BADGE(S) INCLUDED IN FAMILY MEMBERSHIP

BADGE #3: FIRST NAME: LAST NAME:

BADGE #4: FIRST NAME: LAST NAME:

NAMES TO APPEAR ON ADDITIONAL BADGE(S), $3.00 EACH, SAME FAMILY

FIRST NAME: LAST NAME:

AMOUNT ENCLOSED: $40.00 New Membership

Badges $3.00 x (Number of Badges)

TOTAL AMOUNT

MAKE CHECK PAYABLE TO SoCalGRS

MAIL TO: RON DEISLER,

4532 GRAYWOOD AVE, LONG BEACH CA 90808-1015

OFFICIAL USE ONLY:

Date Received:

Check #