Membership Form 

(Please Print)

THE GOLD SHIELD FOUNDATION, INC.
P.O. Box 271791
Tampa, Florida  33688-1797

Membership Application
for  Hillsborough, Pinellas, Citrus, Hernando, Pasco, Polk & Marion Counties

I hereby make application for membership in the Gold Shield Foundation, Inc.,
subject to its by-laws , rules and regulations.

Name _______________________________     Spouse__________________________________

Address _____________________________     Phone __________________________________

City _____________________   County _______________  State _______  Zip Code __________

Business Affiliation ________________________________________   Title _________________

Address _____________________________     Phone ___________________________________

City _____________________   County ________________ State _______  Zip Code __________

I'm enclosing my $100 initiation fee. I understand that hereafter my dues will be $100.00 annually.

Name of Sponsoring member supporting this application: ________________________________

I agree and understand that I will not use this membership, if granted, to gain favors in connection

with the violation of any law or ordinance.

Signature of applicant _____________________________________________________________

                   Please mail this completed application & payment to the address shown above.