Application

Tri-State Prime Timers
Membership Application and Directory Questionnaire

This page is set up as an electronic form.
Type in the information requested then use the "PRINT THIS PAGE" button to make a copy for mailing.

First Name (as you wish it on your name tag)

Last Name

Birthday (including year)

Partner's Name

Attach Separate Application Form/Questionnaire with Partner's Data

Anniversary (including year)

Mailing Address

Street:

City:

State: Zip Code:

Phone Numbers
(include area code)

Voice:

Cel:

Fax:

Email Address(es)

Primary:

Alternate:

I prefer to receive Tri-State Prime Timers materials via E-mail or U.S. Postal Service.
E_MailUSPS

Signature ___________________________________________
(please sign after printing page)
Date

Discretion is paramount in all actions and activity of Tri-State Prime Timers. Personal information will be kept confidential unless you give permission below to publish all or part of it in Tri-State Prime Timers materials.

This application cannot be accepted unless the following six questions are answered:

1. I understand that the Tri-State Prime Timers Directory is given only to Tri-State Prime Timers Members to use for informational purposes. Members are to keep the Directory private and confidential
Yes

2. I permit Tri-State Prime Timers to print the information on this page in the Directory and Newsletter
Yes

3. I permit Tri-State Prime Timers to mail Prime Timers materials to me at the mailing address above.
Yes No

4. I understand that Tri-State Prime Timers does not discriminate on the basis of race, color, creed, national origin, or HIV status
Yes

5. I understand that the use of illegal drugs is not permitted at Tri-State Prime Timers functions
Yes

6. I am at least 21 years of age
Yes

For the Membership Directory, Indicate Your Interests by Checking as Many Two-Letter Codes as Apply:

AC = Antiques BA = Ballet BC = Bicycling BI = Bisexuality BO = Bowling BR = Bridge CA = Concerts, Attend CG = Card Games CK = Cooking CO = Companionship CP = Computers DA= Dancing DI = Discussion DO = Dining Out ER = Erotica EX = Exercise FL = Flea Markets, Yard Sales GA = Gardening GB = Gay Bars LR = Long-Term Relationships MG = Massage	ML = Music, Listening MO = Movies, Cinema MP = Music, Participate MT = Motorcycling MU = Museums/Galleries MV = Movies, Home Video NU = Nudism OP = Opera PE = Penpaling PH = Photography RE = Reading, Book RV = RV-ing, Motor Homes SA = Sports, Attending SI = Singing SP = Sports, Participating SW = Swimming TC = Telephone Talk TH = Theater TR = Travel VT = Volunteering WK = Walking
XX = Other (Please Specify):

Check One:

New Membership
Renewal/Update Membership

Annual Membership Dues
(Due Jan. 1)
(Check One:)

$20.00 - Annual Individual
$10.00 - Annual Individual (after July 1 of current year)
$20.00 - Annual Individual (after Octoer 1 of current year - includes all of following year)
$30.00 - Annual Household*
$15.00 - Annual Household* (after July 1 of current year)
$50.00 - Three-Year Individual
$65.00 - Three-Year Household*

*(Household memberships include two members at the same address.)

Payment Method (Check One):

Check payable to Tri-State Prime Timers
Cash

Mail your completed application to:

Tri-State Prime Timers
P.O. Box 34
Cincinnati OH 45201-0034