First Name: Middle Initial: Last Name:
Years in Current Position: Years as Superintendent:
Job Title: GCSAA Member: Yes No
Club/Co. Name:
Address for Mail:
City: State: Zip Code:
Office Phone: () - Fax: () -
Cell Phone: () - Home Phone: () -
Pager: () - Email Address:
Attestor_____________________ Attestor Signature________________________
Member Signature_____________________ Date:
Annual Dues($100.00)
New Membership Fee ($5.00)
Amount Paid: $
CTGCSA, P.O. Box 19553, Austin, Tx, 78760