Please complete the application form below and send it with your membership fee of $5.00 to the address below. The program year runs for one year from January 1 thru December 31 only; dues are not pro-rated.

Last Name: ________________________________________________

First Name and Middle Initial: _________________________________

Street Address: _____________________________________________

City, State, Zip: ___________________ Home Phone: ( ) __________

E-mail: ____________________________________________________

Make check payable to Pioneer Singles Group and send it along with completed application to:

Betty Conway
780 East Brooke Lane
Rochester, NY 14618

OFFICE USE ONLY

Amount Paid: $__________ Check No: ______ Date: ______