Bellevue Civic Association
	Membership Form
	Please print, complete, and return to:
	Bellevue Civic Association
	P.O. Box 15623
	Bellevue, VA 23227-5623
Name		__________________________________________________________
Street Address		__________________________________________________________
		__________________________________________________________
		__________________________________________________________
ZIP		_______________________________
Phone		_______________________________
Email Address		________________________@___________________________._____
Family Size		______
Dues are $15 per family each calendar year
Amount enclosed		$_________
Would you like to serve on a Civic Association Committee?  (Please check)
_______		Membership
_______		Fundraising/Finance
_______		Newsletter
_______		Programs
_______		Neighborhood Watch
_______		Education
_______		Neighborhood Preservation
_______		Garden Walk
_______		Neighborhood Clean Up
Suggestions/comments? ________________________________________________________________________ _____________________________________________________________________________________________ _____________________________________________________________________________________________