NAME: _____________________________________________

ADDRESS: ___________________________________________________________

CITY/TOWN: __________________________ ZIP CODE: ___________________

PHONE #: HOME_____-_____-________ OTHER _____-_____-________

E-MAIL ADDRESS: ________________________@________

STATION ASSIGNMENT: ________________ SHIFT: _____

FREE T-SHIRT (circle one)       S          M         L          XL          XXL

SUGGESTIONS FOR ACTIVITES:

________________________________________________________________________

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Dues are 3 years for $15.00, payable upon application. Payments are accepted in                                                    CASH or CHECK (payable to FAIRFAX FIREFIGHTER’S EMERALD SOCIETY).                                              Mail Application To:

Mike Lee

12954 Centre Park Cir. Apt. #103

Herndon VA 20171