PRA MEMBERSHIP APPLICATION

HERE’S WHAT MEMBERSHIP ENTITLES YOU TO TAKE PART IN:

      . SEMI-ANNUAL SOCIAL GATHERINGS

      . QUARTERLY NEWSLETTER

      . MEMBER ROSTER

      . ACCESS TO RETIREE WEB SITE

YEARLY DUES:  $10.00        LIFE TIME MEMBERSHIP:  $100.00

MAKE CHECK PAYABLE TO: POLAROID RETIREES ASSN. INC.

MAIL TO:  POLAROID RETIREES ASSOCIATION

               141 NEWBURYPORT TURNPIKE-- BOX 314

                ROWLEY, MA 01969

PLEASE PRINT:

NEW __    RENEWAL  __   LIFETIME MEMBERSHIP  ___  ADDRESS CHANGE  ___

NAME (PRINT)_________________________________________________________

                            LAST NAME                             FIRST NAME                                    MI

ADDRESS ___________________________________________________________

CITY _______________________ STATE _________ ZIP ___________

SPOUSE'S NAME ______________________ PHONE ______________

E-MAIL ADDRESS ___________________________________________

DATE OF RETIREMENT* _________EMPLOYEE # _______ AGE _____

                                                                                          (OPTIONAL)

     * If retired.  It is not necessary to be retired to be a member of the PRA