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District: Area: Club Number: Name of Remitter: Position/Title: Form of Payment: (Please check applicable box) Check/Cheque/Money Order International Wire Payment Allocation of Payment INTERNATIONAL DUES ONLY Membership Dues & Fees MEMBER DUES RENEWAL Full Year MEMBER RENEWAL TOTAL Dues/Fees US$ 80.00 US$ 80.00 Number of Members Total Amount in US$ NEW MEMBER Full.

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