|

(Note!!  Use your mouse or TAB key to move from field to field.  DO NOT use the RETURN key as this will cause the form to be sent IMMEDIATELY!)

  

  Step #1 : Tell us about yourself

 I wish to subscribe to the Colonial Club Super Senior Program

Name:  Date:
Street:
City:      State:  Zip:
Tax Jurisdiction (where you vote):
Telephone:

$ 55.00 -One Super Senior Self:
  $110.00 - Two Super Seniors  
      (Name of the second person)  
         
         
Please consider Super Senior Scholarships. To create one, or to apply for one, call Becky at (608) 837-4611, ext. 102.