MULTIPLE OWNERS DESIGNATING FORM

DATE: ______________

SUB: _______________BLOCK _______________: LOT: _______________

The Bella Vista Property Owners Association records show ownership of the above
referenced property in the names of:

1. _______________________________________________________

2. _______________________________________________________

3. _______________________________________________________

4. _______________________________________________________

We would like membership cards and all computer mailings to be in the names of:

1. _______________________________________________________

2. _______________________________________________________

Signature: _________________________________________________

Signature: _________________________________________________

Signature: _________________________________________________

Signature: _________________________________________________

Accepted by POA Employee: _________________________________

Requests should be dropped off at the POA General Office at Town Center or mailed to:

Bella Vista Property Owners Association
Attn: Membership Services
101 Town Center
Bella Vista, AR. 72714

Phone: (479) 855-8000
Fax: (479) 855-8006

01/20/2005