Revised 4/30/2007

DATE: _______________________________________

NAME(S): _________________________________________________________

ADDRESS & PHONE NO: _____________________________________________

__________________________________________________________________

BIRTHDAY(S) & ANNIVERSARY: ______________________________________

PLACE OF EMPLOYMENT: ___________________________________________

OTHER ORGANIZATIONS ACTIVE IN AND POSITIONS HELD: ______________

__________________________________________________________________

__________________________________________________________________

SPECIAL INTERESTS & TALENTS:_____________________________________

__________________________________________________________________

ABLE TO SPEAK, READ OR WRITE SPANISH?___________________________

                                                                               (Not required for membership)

I/WE WISH TO APPLY FOR MEMBERSHIP IN THE QUAD CITIES MEXICAN-

AMERICAN ORGANIZATION AND FULLY PROMISE TO ABIDE BY THE BY-LAWS

$12.50 per single membership.)

Membership in this organization requires members to volunteer at a minimum of 6

events during the year.  This can include volunteering at dances, helping with Bingo,

and any other event where the help is needed of members.

SIGNED: _______________________________

     _______________________________

SPONSORED BY:

Please mail payment and application to: Quad Cities Mexican American Organization,

P.O. Box 2557, Davenport, IA  52809-2557.