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FOR OFFICE USE ONLY

Name: ___________________________________  Phone: _______________________________________
Address: ________________________________________________________________________________
Primary Reason For Joining THE WORKMEN'S CIRCLE:
q Jewish Cultural Activities
q Jewish Books, Videos and Audio Cassettes
q Jewish Schools
q Yiddish Classes
q Jewish Children's Camp (Camp Kinder Ring)
q Adult Summer Resort (Circle Lodge)
q Public Affairs / Social Action
q Comprehensive Major Medical Plan
q Catastrophic Major Medical Plan
q Medicare Supplement
q Long Term Care Plan
q Hospital Income Plan
q Prescription Drug Plan
q Emergency Medical Response System
q Dental Program
q Medical Services
q Social Services
q Travel Services
q Discount Phone Service
q Auto / Home / Boat Insurance
q Pre-Paid Legal Services Program
q Cemetery / Funeral Benefits
q Geriatric Centers
q Local Branch Activities
q Life Insurance / Disability Income Plans

Other:  (Please use all space necessary, continuing on additional sheets if required.):