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                                           STARTING OVER SINGLES                                      
                                                      P.O. Box 310 
                                       Hicksville, New York   11802-0310
                                          www.StartingOverSingles.com

 
                        APPLICATION FOR MEMBERSHIP  ($52.00 per year) 

                       Please PRINT all information neatly on appropriate lines

 

 ____________________________________________________________________________________________
First Name                                            Initial                   Last Name 

 

____________________________________________________________________________________________
Street Address                                                                                               Apartment #

 

_____________________________________________________________________________________________
City                                                                          State                             Zip Code 

 

_____________________________________________________________________________________________

Driver’s License Number

 

_____________________________________________________________________________________________
Phone Number                                    Listed         Unlisted                   Email Address

 

_____________________________________________________________________________________________
Marital Status:     Divorced     Separated      Widowed     Never Married        Birthdate

 

_____________________________________________________________________________________________
Children?        Yes     No         

 

Have you ever been convicted of a felony?     Yes     No

 

I understand that my membership is not transferable to any other person,                                 under penalty and forfeiture of my membership.

We, at SOS, expect certain “Standards of Conduct” at our events, and if                                    these standards are not met the Member can have his/her Membership taken                            for the remainder of their one year contract.

 

Applicant’s Signature ___________________________________________________

 

Cash      $______________                     Today’s Date_____________________

 

Check    $______________                     Check No.________________

**********************************************************************************************************


Starting Over Singles’ Authorized Signature__________________________________

 

Issue Date _____________________          Membership No.______________________

 

Renewal Dates __________     __________    __________     __________     _________      

********************************************************************************************************

Receipt:  Membership No.____________________          Issue Date_________________

 

Applicant’s Full Name (Printed)_______________________________________________

 

Cash    $____________      Check    $____________     Check No.____________

 
SOS Authorized Signature___________________________________________________