Behind Badge the
July 2013
100 Club of Arizona
5033 N. 19th Ave. Ste 123 Phoenix, AZ 85015 602-485-0100 Tel 602-242-1715 Fax info @ 100club. org www. 100club. org
Executive Director Sharon Knutson-Felix
President George Weisz
Vice President Kathy Mayberry
Secretary Steve Horrell
Treasurer Kara Kalkbrenner
2013-2014 Board of Directors Sharon Allen Bud Davidson Mike Galloway Mark Hester John Jennings Erick Johnson Howard Lang Bill Langer Chris Moore Jim Ryan Joe Scheid Scott Wede Ron Westad
100 CLUB OF ARIZONA Is a charitable non-profit Arizona Corporation( Az. Corp. # 00082094-4). Federal 501( C)( 3)
T. I. N. 23-7172077
Membership Application
Name:( First) _____________________________( Last) ______________________________________________
Mailing Address: ______________________________________________________________________________ City: _____________________________ State: _______ Zip: _____________ Phone: _______________________
Email Address: __________________________________________ Date of Birth: __________________________ Referred by: _____________________________________ Permission to Email you? ________ Mail? __________ Do we have permission to publish your name in the next Quarterly Newsletter? ____________________________
Membership Choice:( Circle one) Individual- $ 150 Joint- $ 250 Lifetime- $ 1,500 Senior- $ 100 Out of State- $ 100
Youth( 13-18)- $ 50 Child( 0-12)- $ 25 Pet( Canine or Feline)- $ 25
Corporate: Basic- $ 500 1 Star- $ 1,000 2 Star- $ 2,500 3 Star- $ 5,000 4 Star- $ 10,000 5 Star- $ 25,000
Joint Members please also provide: Second Member’ s Full Name: ________________________________ Email: _________________________________________
Corporate Members please also provide: Company Name: ____________________________________________ Title: ________________________________________
Company Address: _________________________________________________ City: ____________________ Zip: __________ Business Phone: ___________________________ Company Website: _______________________________________________