MEMBERSHIP APPLICATION FORM

Name _______________________________________	Spouse ____________________
No. of Children under age 18 ________ Names __________________________________
Address _________________________________________________________________
City __________________________________ State _____ Zip ______________-_______
Phone (_____) _____-__________Email address_________________________________
Geologic Interests and Hobbies________________________________________________
Check type of Membership: Individual $25.00 ___ Family $35.00 ___Student $15.00 ___
Check status of Membership: New Member ___ Renewal ___

Please include a check with your application form for the appropriate amount. Make Check Payable to: