Hill 4-11 Association

Membership Dues Form

(Please print and then complete form)

Current members wishing to pay dues, please use this form and mail as instructed below:

Name and Address:



City:_______________________  State:________  Zip:____________

Phone:___________________  E-mail Address:___________________

Date:__________________  Signature:_______________________________________

Membership Dues:  [  ] $25.00 Annually or [  ] $150.00 Lifetime Membership

Please make check payable to Hill 4-11 Association and mail it along with this form to:

Hill 4-11 Association
ATTN: Dick Hill, Treasurer
630 Woodside Dr.
Kent, OH 44240-2664