2001 Tiwahe Lodge #45 Annual Dues

NAME:___________________________________   PHONE: (    ) _______-___________

ADDRESS:__________________________________________________________________

CITY:________________________________   STATE:________   ZIP:__________

E-MAIL ADDRESS: ____________________________________________________________

BIRTH DATE:___________________   CHAPTER:___________________________________

ORDEAL DATE:__________  BROTHERHOOD DATE:__________  VIGIL DATE:__________

FEES:		$7.50 per Arrowman per Year		____ X $7.50 =_________

FAMILY RATE:	$5.00 per each additional family member	____ X $5.00 =_________
(Applied only if registering at the same time
and separate form used for each memeber)		TOTAL: _______________

MAKE CHECKS PAYABLE TO:     BSA  (Account # 1-2371-000-00)

MAIL TO:	Tiwahe Lodge #45, Boy Scouts of America, 1207 Upas St., San Diego, CA 92103

----------------------------FOR OFFICIAL USE ONLY (Do not write below this line)-----------------------------
Date Received:___________   Amount Received:___________   Receipt Number:__________