THE CINCINNATI MINERAL SOCIETY
NEW Membership form
MEMBER NAME_______________________________________________BIRTHDAY____________
RELATED ADULT______________________________________________BIRTHDAY____________
ADDRESS____________________________________________________________________________
CITY STATE ZIP______________________________________________________________________
PHONE ( ____)______________WORK PHONE (____)______________E-MAIL_______________
CHILDRENS NAMES & BIRTHDAYS___________________________________________________
_____________________________________________________________________________________
SPECIAL INTERESTS (CIRCLE) : MINERAL LAPIDARY FOSSILS FACETING JEWELRY FIELD TRIPS
Willing to help by: ( ) serve as officer ( ) serve on committee ( ) help with the show
( ) presentation or teaching ( ) study groups ( ) social functions ( ) display work
How did you find out about us________________________________________?
( ) SINGLE MEMBERSHIP ( ) FAMILY MEMBERSHIP
ANNUAL DUES ARE $15 PER PERSON
$20 PER FAMILY + $1 per kid (AT ONE ADDRESS) January-December.
MAKE CHECKS PAYABLE TO CMS
SEND FORM TO: JUDY BUDNIK; 2948 RONTINA DR.; GOSHEN OH 45122-9300
(CIRCLE ONE) CASH CHECK $______________ Date ___________________
Date received______________________ Date approved as member_______________________