GCSM Membership Form

                                      Name ________________________________________________________________

                                      Employer _________________________   Position _______________________

                                      Information for roster:  Preferred  Home _______  Business _______

                                      Business Address __________________________________________________

                                      City _________________________   Zip Code _________________

                                     Business Telephone Number _______________________________________

                                     Business Mobile Number ____________________________________________

                                     Business Fax Number _______________________________________________

                                     Business Email Address _____________________________________________

                                     Home Address _______________________________________________________

                                    City ______________________________  Zip Code _________________

                                    Home Telephone Number ___________________________________________

                                    Home Mobile Number _______________________________________________

                                    Home Fax Number ___________________________________________________

                                    Home Email Address ________________________________________________

                                    Mail to:

                                                     Margaret Faircloth

                                                    1291 Triple Hill Drive

                                                     Macon GA 31206

                                  Membership is $25 per year - January to January