GUJARATISAMAJ OF DETROIT    ----   MEMBERSHIP FORM – 2019

Below is the form which needs to be completed. All fieldsare required and please fill the form in CAPITAL LETTERS.

  Family Membership

 Senior Membership

Family Membership Fee: $50.00  & Senior Membership Fee: $25.00. If by check, make check payable to GujaratiSamaj of Detroit.


Mail to: Vishal Patel 24826 Brentwood Dr, Brownstown, MI 48183

Primary Member Info

First Name____________________             MiddleName ____________________         LastName _______________________

Gender:______________________               Date of Birth (MM-DD-YY):_____________________

EmailAddress (This will be used for your Login ID):____________________________________________________

Contact Info

MobileNumber (This will be used for your Login ID or Email address):______________________________

Home Phone:________________________ Whatsapp Number:______________________Office #: _________________

Address

Address Line1: _____________________________________________________________________

City:_________________________________            State:_______    Zip Code:________________________

Newsletter & Samaj Subscription

Newsletter(Circle One):  All   /  Events Related Only  SamajDarshan (Circle One): Both / Electronic mail / Post Mail

Spouse Information

First Name:_______________________ Last Name: _______________________________________

EmailAddress (spouse can use their own email to login to website):__________________________________________

Relation: Spouse                Date ofBirth (MM-DD-YY): ______________________             Gender: _____________

Additional Members (Additional members can be added at the back ofform or on separate sheet of page)

First Name:______________________________   LastName: _____________________________

Date of Birth (MM-DD-YY): ___________               Gender: _________

First Name:______________________________   LastName: ____________________________

Date of Birth (MM-DD-YY): ___________               Gender: _________

Newsletter(Circle One):  All   /  Events Related Only

NOTE: If You want to do Recurring Payment each year andrenew your membership, fill below Credit Card Info and each year in January,you membership will auto renew.

Credit CardType (Circle one): Visa / MasterCard, American Express. If others Typehere: _____________________

Name onCredit Card: _____________________________

Credit Card#: _______________________________________ Expiration Date (MM/YY):_________________  CCV Code: ___________

BillingAddress if different then above: __________________________________________________________________________

GSOD Membership

Lifetime Membership: Lifetime affiliation with Samaj

Family Membership: Husband, wife, unmarried children under 25 years of age, and parents living in the same household

Single Membership: Single as defined by IRS

Senior Membership: One spouse is 62 years of age or above

GSOD Sponsorship

Gold: 4 Tickets – Holi, Navratri, and Diwali Program (Each event)

Diamond: Provide 1 Table during the event (if required)

Silver: For events E-Blast, we will put Silver sponsors name at bottom of the email

Diamond: Include Full Color Page Ad for Samaj Darshan

Platinum: 10 Tickets – Holi, Navratri, and Diwali (VIP Seats) Program (Each event)

Upcoming Events