Member Email Address: ­­­­­­­­­­­­_____________________________________________

SECTION 1:   MEMBERSHIP CATEGORIES & FEES

Family Membership

Husband, wife, unmarried children under 25 years of age, and parents living in the same household. Due Date for Renewal is May 31, 2023.

Please note:

Membership renewal fee will be $50 after May 31, 2023.

 $50 NEW MEMBER or
      RENEWAL after 5/31/23

 $50 RENEWAL
      (before 5/31/23)

Single Membership

Single as defined by IRS (Only one person is allowed)

 $25

Senior Membership

One spouse is 62 years of age or above (Only two person are allowed)

 $25

Life Membership

Lifetime affiliation with Samaj

 $751

Corporate Membership

Corporate Membership

 $101

SECTION 2:   MEMBERSHIP INFORMATION

Member’s Full Name:         

Age:          yrs

Spouse’s Name:         

Age:          yrs

Child Name:         

M / F

Grade:         

Age:          yrs

Child Name:         

M / F

Grade:         

Age:          yrs

Child Name:         

M / F

Grade:         

Age:          yrs

Child Name:         

M / F

Grade:         

Age:          yrs

Father’s Name:         

Age:          yrs

Mother’s Name:         

Age:          yrs

Street Address:          

City:          

State:     MI

Zip:          

Telephone  (required):          

Email:         

Gujarati Samaj, Inc. will maintain address and e-mail information with strict confidence and will not use / give it to others for solicitation.

SECTION 3:   ACKNOWLEDGEMENT & AUTHORIZATION

I,                                                                            undersigned understand that this membership application will be reviewed by Secretary of Gujarati Samaj, Inc. I also understand that the membership fees are non-refundable. The above information is true and correct to the best of my knowledge. I understand that any misrepresentation or falsification will result in the cancellation of my membership and I will be responsible for non-member fees if the membership was used during any of Samaj’s events, such as Holi, Navratri, Diwali and other events. By providing the contact information above, I understand that GSOD may communicate with me via phone, e-mail or USPS.

SIGNATURE:  ______________________________________

DATE:                   ___________

Please Make Check Payable to: Gujarati Samaj, Inc.

Form & Check Mailing Address:  G.S.O.D., C/o Sarthak Patel 4310 Pond Run, Canton, MI 48188

Questions? Please send an e-mail to Secretary@GSOD.org

FOR GSOD OFFICIAL USE ONLY:

Payment for 2023 Gujarati Samaj, Inc. Membership received:                                                 Secretary:

Date Form Received:

Check Amount: $

Check Date:

Check #: