I hereby make application for membership in the Camp Sertoma Club of South Carolina. This application is accompanied with a remittance of $100 in payment of annual dues. The club meets once a year at the Regional Convention.

Applicant Name: ___________________________________________

Address: _________________________________________________

City, State, Zip: ____________________________________________

Home Telephone: __________________________________________

Office Telephone: __________________________________________

Fax: _____________________________________________________

Email Address: ____________________________________________

Sertoma Club (if applicable): _________________________________

Signature: ________________________________________________

Recommended by: _________________________________________

Date: ____________________________________________________

Return this application and your check made payable to Camp Sertoma Club