South River City Citizens Membership Form

(revised February 2010)

Membership Levels, Per Year Or Multiple Years

___________ Single $20 x Number of Years ____ = $ ___________

___________ Family $35 x Number of Years ____ = $ ___________

Additional donation to SRCC General Fund $_______________ (Big Bubba/Bubbette)

Total Amount Paid $ ____________________

Date Paid:__________________

Name(s)_________________________________________________________________________

Address: ________________________________________________________________________

Phone(s):________________________________________________________________________

Email(s): ________________________________________________________________________

Send check made payable to SRCC, along with completed form to:

SRCC

Attention: Treasurer

P.O. Box 40632

Austin, TX 78704

Dues and Contributions are not tax deductible.