BECOME A MEMBER

Please print this form & mail it, with your check or money order, to:

 Massachusetts Senior Action Council
150 Mt. Vernon Street, 2nd. Fl., Dorchester, MA 02125

Name __________________________________________________

Street __________________________________________________

City _______________________ State _____ Zip Code _________

Phone _______________ e-mail ____________________________

Please check all that apply

__ $10 - for 1 annual individual membership

__ $15 - for 1 annual couple membership

__ $50 - for 1 annual affiliate organization membership

______ $ to renew ______ membership for ___ years

__ $50 - for a single lifetime membership

__ $75 - for a couple lifetime membership

__ I am a union retiree. Union: ____________________________

__ An additional, tax deductible gift of $_______ is enclosed

     to support MSAC's work.

Please allow 4 weeks for processing.