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Membership Application
$25.00 Individual Membership
Name:_________________________________________________________________________________
Address:_______________________________________________________________________________
City:______________________________________ State:_________________ Zip:_________________
Social Security #:__________________________________ Birthdate:____________________________
Home Phone:______________________________ Work Phone:_________________________________
E-mail Address:_________________________________________________________________________
Additional Family Members ($5.00 each)
Name:__________________________________________ Age:___________________
Name:__________________________________________ Age:___________________
Name:__________________________________________ Age:___________________
Please print plainly and return form with check to:
ADCTA - Kim Vickrey -110 North Hunter Lane - Jonesboro, AR
72401