Application for Membership

<body leftmargin="30"> <center> <h2><font color="#000080">Application for Membership/Renewal</FONT></H2></CENTER> <p align="CENTER"><font color="#000080"><b>Please complete the form below and print it on your printer</B>. </FONT></P> <p align="LEFT"><font color="#000080">Annual dues are $25 (U.S.) for family membership. "SAVM Years" run from December to December so dues are payable each January.</FONT></P> <p align="CENTER"><font color="#000080">Make checks out to <b>SAVM Dues</B>.</FONT></P> <center><font color="#000080">Mail the completed form and dues to:<br><br> <b>SAVM Dues, 5000 Green Meadow Drive, Helena, MT, 59602. <br><br>Include the printed membership form with your dues.</B></FONT></CENTER> <form> <p><font color="#000080"><b><tt>Name: </TT></B><input size="35"><img src="filler1.gif" width="60" height="10"><tt><b>Vet? (Y/N):<input size="1"></B></TT></FONT></P> <p><font color="#000080"><tt><b>Complete the following items only if different from your last application:</B></TT></FONT></P> <p><font color="#000080"><tt><b>Address:</B></TT><input size="50"><br><input size="58"></FONT></P> <p><font face="#000080"><b><tt>City:</TT></B><input size="30"> <b><tt>State:</TT></B><input size="5"> <b><tt>Zip Code:</TT></B><input size="15"></FONT></P> <p><font color="#000080"><tt><b>Country:</B></TT><input size="25"></FONT></P> <p><font color="#000080"><tt><b>New Member? (Y/N):</B></TT><input size="1"></FONT></P> <p><font color="#000080"><tt><b>Phone:</B></TT><br><img src="filler1.gif" width="60" height="10"><tt><b>Work :</B></TT><input><img src="filler1.gif" width="60" height="10"><tt><b>Home :</B></TT><input><br><br><img src="filler1.gif" width="60" height="10"><tt><b>Email:</B></TT><input size="30"><br><br><img src="filler1.gif" width="60" height="10"><tt><b>Fax : </B></TT><input></FONT></P> <p><font color="#000080"><tt><b>Diver? (Y/N): </B></TT><input size="1"></FONT></P> <p><font><tt><b>Certifying Agency:</B></TT><input size="30"></FONT></P> <p><font color="#000080"><tt><b>DAN Member Number:</B></TT><input><img src="filler1.gif" width="60" height="10"><tt><b>Expiration Date:</B></TT><input size="10"></FONT></P> <p><font color="#000080"><tt><b>Do you have DAN Insurance? (Y/N):</B></TT><input size="1"></FONT></P></FORM> <center> <p align="CENTER"><br><br></P> <table border="0" align="CENTER" bgcolor="#FFFFFF"> <tr> <td><a href="mailto:savm@earthlink.net">Email SAVM</A></TD> <td><a href="index.htm" target="_top">SAVM Home</A></TD> <td></TD> <td></TD></TR> <tr> <td></TD> <td></TD> <td></TD> <td></TD></TR></TABLE></CENTER></BODY>