logo Los Angeles Prime Timers
MEMBERSHIP / RENEWAL APPLICATION
http://www.laprimetimers.org/

For office use only:
__________ __________
Member No. Exp. Date
Please complete the form
first, then print it, sign it
and send it in with your check.
Date:
NEW MEMBERSHIP
RENEWAL / UPDATE
Annual Membership:
$40 per person
$60 per couple (must have same address)

Member Profiles:
Add $10 to receive member profiles

Please mail us your completed
1. Application
2. Questionnaire
3. Check

Los Angeles Prime Timers
P.O. Box 191728
Los Angeles, CA 90019-1028

Full Name:

Birthday (incl yr):

Mailing Address:

Apt # :

City:

State:
ZIP:
 		Country:
Home Phone:
Email Address:
 		Occupation:
Notify in case of an emergency:
Full Name:
 
Telephone:
Address:
 		City:
State:
 		ZIP:

NO PERSONAL INFORMATION OF ANY MEMBER WILL BE PUBLISHED ON THE INTERNET. Discretion is paramount in all actions and activity of Prime Timers. Personal information will be kept confidential unless I give permission to publish all or part of it in Prime Timers materials. I understand that the Prime Timers Profile is given only to members. I agree to keep the profile private and confidential among Prime Timer members only.
  Select One  
I permit Prime Timers to print & mail my Profile to members.
I permit Prime Timers to mail the Prime Timers Newsletter to me.
I permit Prime Timers to mail the Prime Timers Profiles to me. { If "Yes," include $10 with
annual membership fee
I am at least 21 years of age.
I heard about Prime Timers from:

________________________________________________
Signature
____________________
Date
Remember to sign this form!
Don't stop here! Proceed to the Profile Questionnaire and fill it out, too.