| Name: | _______________________________________ | ||
| Institution (if any): | _______________________________________ | ||
| Street Address: | _______________________________________ | ||
| City: ____________________ | State: ___________________ | Zip: ___________________ | |
| Phone: Work (_____) _____-_______ |
Home (_____) _____-______ | Fax (_____) _____-_______ | |
| E-Mail Address: | _______________________________________ | ||
|
Interest Areas: Topical Interests: |
Conferences________ Newsletters________ Workshops __________ _______________________________________________________ |
||
| New Member: ______ | Renewal: ______ | ||
|
Individual $25 |
_____ |
Make check payable to: OHMAR |
|
Student $10 |
_____ |
Mail to: |
|
Institutional $75 |
_____ |
OHMAR |
|
Life $1,000 |
_____ |
c/o Madelyn Campbell |
|
Contribution |
_____ | 227 S. College St. |
| TOTAL ENCLOSED | _____ |
Carlisle, PA 17013 |
| Questions: ohmar.treasurer@gmail.com |
