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2010 NEW MEMBERSHIP APPLICATION OR MEMBER RENEWAL FORM If you have not yet renewed, please do so soon!!! Your support is appreciated! Name (Please Print)____________________________________________ Date _______________________ Company Name ___________________________________________________________________________ Mailing Address _____________________________________________________________________________ City _______________________________________ State ______________________ Zip ______________ Home Phone ___________________ Work Phone___________________ Fax No. ______________________ Email address:_________________________________________________________ List Blaster Licenses Held ___________________________ Are you a member of the I.S.E.E.? ____________ I hereby apply for ____________Membership / _____________Renewal of Membership in the Chapter. A check payable to Eastern PA Chapter I.S.E.E. to cover my dues is enclosed. Chapter Dues are $30.00 per year. If accepted for membership, I agree to comply with the Constitution, By-Laws and Regulations of the Chapter. Make checks payable to: Eastern PA Chapter I.S.E.E. send to: Sheryl Tomlin American Rock Mechanics Inc. 7531 Chestnut St. Zionsville, PA 18092 __________________________________________ IF YOU WISH TO RECEIVE NOTIFICATION OF THE CHAPTER NEWSLETTER VIA EMAIL PLEASE CHECK THIS BOX. (YOU WILL NOT RECEIVE A NEWSLETTER IN THE REGULAR USPS MAIL.) Make sure you include your email address in the space provided above. |
