Please, print this form.

2008 NEWApHC Membership Application

NAME:___________________________ ApHC # ____________

ADDRESS: ___________________________________________

CITY: _____________________ STATE: _____ ZIP:__________

PHONE: _____________ EMAIL:__________________________

NEW: ______ RENEWAL: ______

Family Members - Relationship - ApHC-AYA-Non-Pro # - Youth Date of Birth

______________________________________________________

______________________________________________________

______________________________________________________

______________________________________________________

Household - $20.00, Individual - $15.00, Corporate - $50.00
Memberships run from January through December.

Return to:
Sandy Truntz
8496 Western Rd.
Cedarburg, WI 53012
Fax: 262-377-5225