XRX Pioneer Club of Rochester, Inc.
 A not-for-profit organization
 (A social organization for seniors [age 50 and older] with an association to Xerox
and/or affiliate companies.) 

2010 XEROX PIONEER GOLF LEAGUE APPLICATION

PLEASE COMPLETE/CHECK   THE FOLLOWING AND SUBMIT, OR PRINT OFF TO MAIL IN.
IF SUBMITTING ONLINE,    PLEASE  U.S.   MAIL MEMBERSHIP  CHECK TO
                                BILL STOLLER,   1631 BRIDGEBORO DR,  WEBSTER, N Y 14580

ENTER  " YES "  IN  CHOICE  BOX :
TEAM    SINGLE PLAYER   

TUESDAY  THURSDAY 

GOLF LEAGUE MEMBERSHIP FEE: $13.00 PER PERSON. TEAM ($26.00)

(PLEASE PRINT )

NAME 

E-MAIL ADDRESS 

ADDRESS 

PHONE NO.

MY TEAM MATE IS 

E-MAIL ADDRESS  

ADDRESS

PHONE NO.

  SIGN ME UP TO SUBSTITUTE ( NO MEMBERSHIP FEE REQUIRED )
(enter Yes or No)

TUESDAY THURSDAY   EITHER DAY  (enter Yes or No in choice box)

MAKE CHECK PAYABLE TO "XRX PIONEER GOLF LEAGUE": AMOUNT
                                                                                                                 (either $13.00 or  $26.00)

( YOU MUST BE A MEMBER OF THE XEROX PIONEER CLUB )

WILL ATTEND GENERAL MEETING ON 4/23/09       (Enter Yes or No )

PLEASE PROVIDE EMERGENCY CONTACT INFORMATION:

1. NAME:  

PHONE NUMBER:

2. NAME:

PHONE NUMBER: