WSO Group # _______________________________________________________

Group Name_________________________________________________________

Meeting Day and Time________________________________________________

Meeting Place________________________________________________________

Name: ______________________________________________________________

Phone: ______________________________________________________________

E-Mail: _____________________________________________________________

Address: ____________________________________________________________

_________________________________________________________________

City __________________________________ State ___________ Zip __________

 

Amount Enclosed _______________________________

Please make check payable to:    Region III OA

Send to:

Region III OA
Barbara Vervenne, Treasurer
PO Box 29903
Austin, TX 78755