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Pirates of the Susquehanna
Parrot Head Club - Binghamton, NY
Web: www.potsphc.org
Email: membership@potsphc.org
Individual Membership $25/yr April - June $18.75, July - Sept. $12.50, Oct. - Dec. $6.25
Couple/Family/Household Membership $35/yr April - June $26.25, July - Sept. $17.50, Oct. - Dec. $8.75
(Memberships are for one household. People, including family, not living at the same address should apply separately.)
Name(s): ______________________________________________________________
Name(s): ______________________________________________________________
Address: ______________________________________________________________
City: _______________________________ State: _______ Zip: _________________
Phone: (H)___________________ (W) ___________________ (C) ________________
Email(s): _______________________________________________________________
Birthday(s): _____________________________________________________________
(Please list birthdays of additional members in the same order that their names are listed above.)
Interests: ____ Club Officer (Pres, VP, Sect.) ____ Newsletter (writing or producing)
____ Web site (content or development) ____ Events (arranging, organizing)
____ Planning (parties, meetings)
Charities you’d like to help: ________________________________________________
How did you hear about the club: ___________________________________________
Comments: _____________________________________________________________
Membership Agreement: By applying for membership in the Pirates of the Susquehanna Parrot Head Club,
you are agreeing to abide by, and to have your membership (and the memberships of anyone whose names
appear on this application) governed by the Bylaws of the Pirates of the Susquehanna Parrot Head Club.
Signature: ______________________________ Date: ____________________
Mail completed application with check or money order made out to: Pirates of the Susquehanna PHC
POTS, PHC
PO Box 5829
Endicott, NY 13763
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