(Please Print)
Name: ____________________________ Spouse's Name: _____________________

Address: _____________________________________________________________

City: _____________________________ State: _________ Zip Code: _____________

Phone: (____) ____________________  E-Mail: _______________________________

Retirement Date: (mm/dd/yy): ___/___/___ Dept: _________ Location: ______________

Address2: ____________________________________________________________

City2: _____________________________ ST2: _________ Zip2: ________________

Phone2: (____) ____ - _____________ Month From: ____ Month To: ____

Membership Dues:
_____ 1 Yr $10.00 _____ 2 Yr $20.00 _____ 3 Yr   $30.00

-----( Office Use Only )----- Member #: _______________

Send Form and Check To: GMLSRC P.O. Box 12255 Lansing, MI  48901-2255

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