Mary P. Gardner
245 East 87th
Street, Apt. 9C
New York, NY
10128
OR BRING YOUR CHECK TO THE NEXT DINNER OR BOARD MEETING
NAME
__________________________________________________________
ADDRESS
__________________________________________________________
__________________________________________________________
PHONE
__________________________________________________________
CELL
___________________________________________________________
EMAIL
__________________________________________________________
BIRTH DATE: Month
____________Day ____________Year (optional) ___________
OCCUPATION – IF RETIRED, FORMER OCCUPATION
_____________________________________________________________
SPECIAL INTERESTS
______________________________________________________