Palestine, Texas 75802-3406

Please indicate number of memberships being registered for each type:

Alumni _______ … if Graduate, what is your Class Year(s): ______

Associate _______

Corporate ______ (attach separate sheet with company name, address, etc.)

Complete Name Now: _________________________________________________

Last Name (Maiden) In School: _________________________________________

Name As Known In School: ____________________________________________

Email Address: _________________________ @ __________________________

Street Address: _______________________________________________________

City: _____________________________ State: ______ Zip Code: _________

Telephone 1: (____) - ________ ________

Telephone 2: (____)_- ________ ________

$ 25.00 Alumni & Associates ______ @ $ 25.00 per year = $ _________

Associate Members are non-graduates of PHS

$ 10.00 Current PHS Students ______ @ $ 10.00 per year = $ _________

$ 100.00 Corporate ______ @ $ 100.00 per year = $ __________

Scholarship Donation $ __________

Total Amount Enclosed $ __________

Are you willing to serve as a Class Contact? Yes ________

For Office Use Only: Cash _______ Check _______ Check # ___________