Mid-Peninsula IBM PC Club Application

Please print this form and fill in the following information. Renewals require only the items marked with an * unless something has changed. Sign the certification of eligibility, and send the application along with a check ($12 for full year, $8 after June 30th for half year, membership) to the address below. Make check payable to IBM PC Club.

All memberships expire on December 31 of year for which paid.

New ___ or Renewal ___* Check No._____* Amount_____*

Check: Active Employee___ Retired___ IBM Spouse/Dependent___

Last Name_____________________* First Name__________________* Init___*

Active Employees only:
IBM Location:_____________ Internal Address (Dept/Bldg/MS)_______________

All Applicants: IBM Serial#____________ (to get Newsletter)

Home Address:______________________________________




Certification of Eligibility:
I hereby certify that I am eligible for membership according to the following membership rule from our club constitution:

"Membership will be open to all IBM employees, and all employees retired under the IBM Retirement Plan or receiving benefits under the IBM Medical Disability Income Plan and their spouses and dependents, who reside in the geographic area served by the Mid-Peninsula IBM PC Club."

Signature:___________________________* Date:_____________________*

Office Use Only: Mail to: (or bring to meeting)
Date processed: George Kornbluth
Form reviewed and check amt. PO Box 2653
Member updated Menlo Park, CA 94026
Date deposited: