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OHIO CHAPTER MEMBERSHIP APPLICATION 

Dues are $5.00 per calendar year. Please print or type the information below.

Member's Name:_______________________________Spouse:___________________? (Spouse should be listed here if you wish it on the roster and he/she is not joining)

Name of Additional Member at same address:____________________________

MAILING Address:________________________________________

City & State:______________________________Zip Code:________  Telephone:____________________ (___) check here if OK to print phone # in roster)

Interested in collecting:__________________________________________________ ? (Disney,Goebel,metal,etc.)

Second member's interests:_________________________________________________ (Same categories &)

How did you find us, or where were you given information about our Club? Ohio Chapters web page

Were you "Referred by" someone?__TRACY NADER__

Are you a current member of the National Shaker Club? You must be a national member to join the Ohio chapter.YES_____ NO_____

What is your internet address?________________________________________________

Make check or mail order payable to: "Ohio Chapter / Salt & Pepper Shaker Club"

Send To: Nancy Sue Johnson, 9777 Hoover Road NE Newark, Ohio 43055