PO Box 105812, Jefferson City, MO 65110

Help Line 1-888-BETSOFF (1-888-238-7633) www.888betsoff.org

PARTICIPATING MEMBER APPLICATION
 Feel free to complete this form here and then print and mail it to the address listed above.

(Name of Organization/Individual)

Applying as an: Individual Organization

   

(Point of Contact-for organization)

 (Title)
 
(Mailing Address)
     
(City) (State) (Zip Code)

     
 
(Daytime Phone w/area code) (Evening Phone w/area code)  
     
 
(E-mail) (Fax)  

 

 

For Office Use Only:

Date Received: _________________20____ Place on Agenda for _____________________ Meeting
Action Taken: Accept Application Reject Application
Applicant notified on_________________ via letter phone email fax
by ____________________________________

.