HUGH PURVIS REUNION ASSOCIATION

	     MEMBERSHIP APPLICATION

             Yes!    Put me down as a dues paying member of the Association. 

                     Annual dues $20.00 ?
                     Make me a lifetime member $ 200.00 ( age younger than 59)?
 		     $150 (age 60 – 69)
		     $100 ( age 70 – 79)
		     $50  ( age 80 and older)
                     Here is something extra to help pay the bills $ __________ 

     
Please make checks payable to the Hugh Purvis Reunion Association and mail to:

Treasurer Ken Quenstedt
PO Box 329
Commack, NY  11725 

Please email me the Purvis Newsletter and save the postage for that snail mail <here>

The Association intends to make available to the Active membership a directory which will include 
much, if not all, of the information listed below. 

If you do not wish to be included in the directory please check the box < here >
and your information will not be included in the directory. 

I am not interested in any of this. Please remove my name from the mailing list  <here>

First name__________________ Nickname ______________Last Name ______________________

Name of that significant other _________________________________________________________

Street address or PO Box  ___________________________________________________________ 

Town __________________________________________ State _______ Zip __________________ 

Email address _____________________________________________________________________ 

Phone (            ) _____________________________ Cell (             ) __________________________ 

Years on board 19 ________ to __________ Rate ____________ Rank_____________ 

The Hugh Purvis Reunion Association thanks you for being a member!

VISIT US ON THE WEB AT WWW.HUGHPURVIS.COM