FOR REGISTRATION & DIRECTORY INFORMATION

TXOKO ONA INC., BASQUE CLUB

P.O. BOX 1163 – HOMEDALE, ID 83628

DATE: _______________________

NAME: ___________________ ___________________

HUSBAND WIFE

___________________ ___________________

SINGLE CHILD

___________________ ___________________

CHILD CHILD

___________________ ___________________

CHILD CHILD

ADDRESS: ___________________________________________

___________________________________________

___________________________________________

E-MAIL ADDRESS: __________________________________

TELEPHONE NUM(S): __________________________________

OCCUPATION(S): __________________________________

For any new member(s), an initiation fee of $10.00 needs to added to the total amount shown below:

MEMBERSHIP: ______________ _______________

(check one) SINGLE ADULT HUSBAND & WIFE

$35.00 $50.00

______________ _______________

SINGLE ADULT HUSBAND & WIFE

WITH CHILDREN WITH CHILDREN

UNDER “18” UNDER “18”

$50.00 $50.00

SIGNATURE: _______________________________________

HUSBAND/SINGLE SIGNATURE

_______________________________________

WIFE/SINGLE SIGNATURE

Check this space if you have already received a membership card: __________