MEMBERSHIP APPLICATION
District Chapter 117 - St Augustine FL

_____ New Membership      _____Renewal

_____Check if you have Paid National CPSA

NAME:______________________________________________________

ADDRESS: __________________________________________________

CITY:  ______________________________________________________

STATE: ______      ZIP CODE: ____________________

EMAIL: _____________________________________________________

PHONE: ____________________________________________________
.Annual chapter dues are $20. The membership year runs from November 1st
to October 31st.    All checks are to be made out to :

DC 117/ St. Augustine, and sent to Joan Franchi, 38 Westmore Lane

Palm Coast, Fl. 32164.

Applications for CPSA can be obtained through the website:  
www.cpsa.org