MID-JEFFERSON COUNTY A&M MOTHERS CLUB

MEMBERSHIP FORM
Please type or print
First Name: ____________________ Last Name: __________________________
Husbands first name: _____________
Street Address: ____________________________________________________
City, State & Zip: ___________________________________________________
Phone # (home & cell): ________________________________________________
Email address: ______________________________________________________
Aggie Mom birthday (month/day): _______________________________________
Are you an Aggie Graduate? If so, what year? ______________________________
Is your husband an Aggie Graduate? If so, what year? ________________________
Types of Memberships:

(Check one)

_____ ACTIVE: Dues are $20 annually

(Members who currently have a student(s) attending Texas A&M)
_____ ASSOCIATE: Dues are $10 annually
(Members who have A&M graduates, but wish to continue their support)
Please bring to the first meeting (1) dues (2) this membership form and (3) student
information form or mail them to:
Gail Pickens-Barger
gaileee@yahoo.com

2841 10th Street, Port Neches, Tx 77651

409-727-3177

Final deadline: October 1, 2013. Make checks payable to MJCAMC.

(Deadline is to print our roster memberships accepted all year long)

For office use only: Method of payment.

Membership type: Active or Associate
Date received: _____________________________________________________
Check amount: ________________________ Check # _______________________