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Name:

Addr1:

Addr2:

City:    State: 

County:  Zip Code: 

Home Phone: 

Cell Phone:   

Work Phone:  

Fax:             

Email:    

Website:

Member Fee: 

Cash:  Check #: 

Date: 

New Members Signature:

____________________________________


Received By:

____________________________________


MEMBERSHIP

Members of the Royal Order of Don Juan Ponce
de Leon Historical V Centennial Celebration
Committee include individuals, businesses,
corporations, and international persons or
entities.

As a member you enjoy participation in
Historical Committee events and programs
while supporting its vital mission.

MEMBERSHIP LEVELS

 Student Membership
 Individual Membership
 Family Membership
 Small Business Membership
 Non-Profit Membership
 Corporate Membership
 Benefactor Membership
 Life Membership
$15.00
$50.00
$60.00
$75.00
$100.00
$150.00
$500.00
$1000.00

International Memberships are available
for an additional $10.00.

 International Membership

Make check or money order
payable to:


Royal Order of Don Juan Ponce de Leon Historical Committee

Mail completed application
and money to:


U.T.B. United Third Bridge, Inc.
Royal Order of Don Juan Ponce de Leon Historical V Centennial Committee
2293 Aurora Rd
Melbourne, FL 32936-0505

For questions regarding membership please call (321) 863-5165, or send us your question at "UTBLOPEZ@aol.com".