NORTH SIDE HIGH SCHOOL ALUMNI ASSOCIATION, INC
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Membership Application
______ New Member _____ Renewal Date______________
_____ $15.00 Member _____ $25.00 Sustainer _____ $50.00 Benefactor _____ $100.00 Patron
_____ $1,000.00 Life Membership (Can be paid at $250.00/year for 4 yrs)
( _____ In addition to my membership dues, I wish to contribute an additional amount to the
Scholarship Fund $___________.
( _____ In addition to my membership dues, I wish to contribute an additional amount to the
Grants Program $___________.
PLEASE FILL IN COMPLETELY EVEN IF NO CHANGES – Thank you!
Name (First) _________________ (Last)___________________(Maiden)____________________ ( Grad Year:_____
Married ____ Widowed_____ Divorced _____ Single ______ ( Date of Birth (mm/dd/yyyy) ____/_____/_____
Spouse’s Name _____________________________ Is spouse North Side graduate? Y / N (circle one)
Spouse’s grad year: ________ Spouse’s Maiden/School Name: __________________________________________
PRIMARY ADDRESS: HAVE SEASONAL ADDRESS? Y / N (please circle one)
Street ____________________________________ Street__________________________________________
City _____________________________________ City ___________________________________________
ST_________________ Zip__________________ ST__________________ Zip_______________________
Phone (______)____________________________ Phone (______) __________________________________
Cell PH# (______)_________________________ Months you will be at seasonal address:
Work PH# (______)________________ Retired? ____ _________ thru _________
E-mail ___________________________________ * needed to receive mail. Our mail cannot be forwarded.
Newsletter Preference: (check one) Mailed Paper Edition_________ Emailed Edition ______________
Please list any noteworthy news for the Totem Tales newsletter: (You may use second sheet if you need additional space.)
_____________________________________________________________________________________________________________________________________
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Credit Cards Accepted: Name on Card ____________________________ Card Number _____________________________
Expiration Date:___________ 3 Digit Code: _____________ Zip Code:
Make checks payable to: North Side High School Alumni Association, Inc.
Mail to: NSHS Alumni Association, 475 East State Blvd., Fort Wayne, In. 46805
Web site and Online Directory:
E-Mail: info@ Telephone: 260-471-4499
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