PLEASE CHECK ONE:

___ PAID MEMBERSHIP SIGN UP
      (Membership is $35.00 per person, payable in check, credit card or money order)

___ DATABASE INFORMATION CHANGES

FILL OUT THE APPLICABLE SECTIONS (Please Print)

Date: _______________

Name: ____________________________ Other Name: ______________________________

Address: ___________________________________________________

City: ________________________ State: ________ Zip: _____________

Phone: (___) _________________ Fax: (____) _____________________

eMail: ______________________________________________________

----------------------------------------------------------------------------------------------------

Check Amount Enclosed: __________________________

----------------------------------------------------------------------------------------------------

Credit Card Information:

Name on Credit Card: ______________________ Credit Card #: _____________________

Expiration Date: __________ CW2 No (last 3 digits on back of card) ______

Card Holder Phone: __________________

Card Holder Address: _________________________________ Zip Code: ___________

Amount to be charged to Credit Card: __________

----------------------------------------------------------------------------------------------------

How do you prefer to receive your newsletter? ___ Email ___ USMail    

Please print out this form and Mail to: Desert Dyners, P.O. Box 5072, Palm Springs, CA 92263-5072 or Phone: 760-202-6645 or eMail: info@desertdyners.com