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LSRC
MEMBERSHIP FORM
 Last Updated: Tuesday, December 22, 2009

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IF it's time for your Annual Dues payment - OR - IF you would like to enroll in our Club - OR - IF you have any changes to your information on file with us, use the handy form below so that we can keep your newsletters coming to you in a timely fashion.

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GMLSRC ENROLLMENT//DUES//CHANGE FORM

NAME  ________________________________________________ SPOUSE'S NAME:  ____________________
 
ADDRESS  __________________________________________________________________________________
 
CITY/ST/ZIP  ______________________________________________________________________________
 
PHONE (____) ____________________  EMAIL  _________________________________________________
 
RETIREMENT DATE (MM/YY)__________   DEPT  __________________  LOC  ________________________
 
SEASONAL ADDRESS  __________________________________________  FROM __________  TO _________
                                                               (Example: FROM 01 TO 04)
CITY/STATE/ZIP  ____________________________________________  PHONE (____) ________________
 
 
FOR ENROLLMENT OR ANNUAL DUES
SEND FORM AND CHECK TO:

GM Lansing Salaried Retirees Club
  Attn: Membership Committee
  P.O. Box 12255
  LANSING, MI  48901-2255
 

3 YEARS  
2 YEARS 
1 YEAR

$30
$20
$10

Member # ________
(Office use Only)
  CHANGES ONLY CAN BE E-MAIL TO:          clubfeedback@gmlsrc.org
  OR MAILED TO THE ABOVE ADDRESS