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_______________________