Membership Application

Name:_________________________________ Date:________________

Family names and relationship:_________________________________________

Address:_____________________________________________

City_________________________ State_______ ZIP_______________

Phone #: (____) ______-_________

Email:_____________________________

Homepage:___________________________________________

Optional information:

Please describe the computer equipment you use.

OS – Win 95___Win 98___ Win ME___ Win XP___ Other:___________

Computer ability: Beginner___ Novice___ Intermediate___ Advanced___

Primary Interest – check all that apply.

Internet___ Email___ Word Processing___ Games___ Genealogy___

Business applications ___ Digital Photography___ Scanning___

Other:__________________________________________________

• Dues: $22 per year for full 12 months.
• OWC Students and Staff - $11.00
• Single or family membership are the same.

Mail completed application with check or money order to:

Chautauqua Cyber Club, Inc.
P. O. Box 251
DeFuniak Springs, FL 32435