The 100 Club Needs You
                   
                      Application For Membership
                           (Please Print)




Name: ____________________________________________________________________


Home Address: _____________________________________________________________


City, State & Zip: ___________________________________________________________


Business Address: ___________________________________________________________


City, State & Zip: ___________________________________________________________


Business Phone: ____________________________________________________________


Home Phone: ______________________________________________________________


__ Lifetime Membership: $1,000
   (total one-time payment)


__ Regular Membership: $100 per year


All Membership Donations Are Tax Deductible
(IRS tax-exempt No. 76-02061811)


Please return this completed application with your check, payable to:
“100 Club of Jefferson and Hardin Counties”


Mail to:
The 100 Club of Jefferson and Hardin Counties
P.O. Box 3405
Beaumont, Texas 77704


For further information, call 409-838-2802