Pine Tree Guide Dog Users Initial Membership Form

Thank you for your interest in joining PTGDU. Please provide the information below.

Annual Dues: $10. If paid after October 1st will provide membership from date of payment through December 31st of the following year.

If you choose to send us a check, please make it payable to Pine Tree Guide Dog Users, and mail the check to P.O. Box 6157, Falmouth, ME 04105. Be sure to include your name and address as entered on this form.

Name

First

Last

Street Address

Apartment, Suite, etc.

City

State or Province

Zip or Postal Code

Country

Primary Phone Number with Area Code

Secondary Phone Number with Area Code

Email Address

Are you, or have you ever been, a guide dog handler?

Yes

You can pay with PayPal, credit or debit card, or by check. Please indicate which method you will use. When you click the SIGN UP NOW button, you will be redirected to a payment page. Thank you!

PayPal

Credit Card

Debit Card

Check (You will be shown the mailing address.)

Other Personal Information

If you are human, leave this field blank.