Head
MEMBERSHIP APPLICATION
Applicant Name : Email :  
Household Address :
City : State : Zip Code : Mobile Number :
Spouse/Additional Applicant Name :
Mobile Number : Email :  
Dependent 1 : Email :   Phone :
Dependent 2 : Email :   Phone :
Dependent 3 : Email :   Phone :
Dependent 4 : Email :   Phone :
Dependent 5 : Email :   Phone :
Dependent 6 : Email :   Phone :
Disclosure & Waiver:By signing this application for the membership of GSH, the applicant(s) agrees to abide by the GSH constitution, Articles, Bylaws, Rules Regulations and Boaed Resolutions, wheather currently in force or subsequently adopted. Furthar, the applicant(s)hereby voluntarily relinquishes the right to hold the GSH, its officers and/or it's volunteers liable for any act or ommission that may result in either legal or moral accountability, whether or not financial in nature, thereby waiving the right to any legal remedy that may otherwise be available at law or in equity. Additionally, with regards to any and all programs sponsored by the GSH(which includes religious ceremonies and festivities), the applicant(s) agrees to, with out dispute, not only honor,respect,dignify the scheduled event, but also to heed and comply with any ritual(including religious observance) as directed by three GSH officer(s) and/or person(s) to whom such authority has been delegated by some/all of the GSH officers. Applicant fully understands and acknowledges that any violation of the terms contained herein shall be regarded as good cause for removal from the particular event, and may also result in suspension, temporary and/or permanent loss of the GSH membership.
 
Applicant Signature :_________________________________________ Date :
Official Use Only (Check Appropriate)
 $40 - Couple Membership (kids 5 and under free)  $25 - Single/ Student Membership
 $751 - Life Membership  $1501 - Patron Membership
 $15 - Each Additional Member # _____ (Up to 6 additional dependents)
Total # Of Members 1 2 3 4 5 6 7 8
Total Amount Paid $25 $40 $55 $70 $85 $100 $115 $130
Method of Payment:  Cash:_____________________      Check (#: _____________________)      Credit Card
 
Received by: ____________________________________________ Date: ______________________
*** This membership is non-refundable and only one copy of Darpan per Household ***





Copyrights@GujaratiSamaj 2016