| PLEASE COMPLETE AS FULLY AS POSSIBLE! |
| pdf versions: download, print and use pen -or- download, fill out with computer, and print |
| Single
Membership or Primary Member (for Couples) |
Couple
Membership Second Member with Same Home Address |
||
| Member Name | ____________________ |
Member Name | ____________________ |
| Position/Title | ____________________ |
Position/Title | ____________________ |
| Organization | ____________________ | Organization | ____________________ |
| Address | ____________________ | Address | ____________________ |
| Address | ____________________ | Address | ____________________ |
| City, State, Zip | ____________________ | City, State, Zip | ____________________ |
| Office Phone | ____________________ | Office Phone | ____________________ |
| Office Fax | ____________________ | Office Fax | ____________________ |
| Primary E-Mail | ____________________ | Primary E-Mail | ____________________ |
| Alternate E-Mail | ____________________ | Alternate E-Mail | ____________________ |
| Home Address | ____________________ | ||
| City, State, Zip | ____________________ | ||
| Home Phone | ____________________ | ||
| Membership Category | |||
| _____ single ($20) | |||
| _____ couple ($25) | |||
| _____ student ($10) | |||
Please bring completed form and check (payable to ETGS) to the next meeting, or mail them to
East Tennessee
Geological Society
Post Office Box 6193
Oak Ridge, Tennessee 37831-6193
Revised January 2012
Page updated May 26, 2018 |