Name: _____________________________________
Date of Application: _ _ | _ _ | _ _
Address: ___________________________________
Address: ___________________________________
City: __________________________
State: ___
Zip: _ _ _ _ _ - _ _ _ _
Telephone:
(home) _ _ _ - _ _ _ - _ _ _ _
(work) _ _ _ - _ _ _ - _ _ _ _
Birthday: _ _ | _ _ | _ _
E-mail address (if applicable): ________________________________
Please e-mail me meeting reminders and items of interest: yes 
no
Special interests or areas of expertise:
_______________________________________________________________________________
_______________________________________________________________________________
_______________________________________________________________________________
Membership dues are $25 annually and are due in January. A pro-rated amount will be due with this application (please see below). Benefits of membership include a club t-shirt (with initial membership) and a plethora of fun and new friends. Please make your check payable to the Parrot Head Club of Richmond and mail it with your membership application to:
Parrot Head Club of Richmond
Attn: Membership
P.O. Box 29423
Richmond, VA 23242-9423
Application Dues
January to March - $25 / April to June - $20 / July to September - $15October to December - $35 (Includes October of current year thru December the following year)
Free T-Shirt with application (for first-time members): Size ________ Total $ _______
Extra Stuff
* Extra T-Shirt (S-XXXL) $12.00 Size ______ Quantity _____ Total $ _________* Sweatshirt (S-XXXL) $20.00 Size ______ Quantity _____ Total $ _________
* Larger sizes available, please inquire about price. Please add $4.00 if you would like your t-shirt mailed to you.
If you are interested in purchasing a gift membership, contact Bob Smalley at BSmalley47@aol.com for details.
Disclaimer: This membership fee is not deductible as a charitable contribution for federal or state income tax purposes. The terms Jimmy Buffett, Margaritaville, Parrot Head(s), Parrothead(s), Parrot Head Club, Parrothead Club and PHC are registered trademarks of Margaritaville Inc.