The Pittsburgh Geological Society
Membership Application & Renewal, 2009 - 2010

Save this file to your computer and print it out. Fill in the appropriate blanks
and send it with payment to John A. Harper at the address listed on the bottom.

First Name: __________________ Middle: _____________ Last: _______________________

Affiliation (Company or School): _________________________________________________

Address For Membership Directory:

Position/ Title (e.g. Geologist, Manager, Student)   _____________________________

Street / PO Address   _________________________________________ Suite/Apt. _______

City  _______________________________ State/Country ________ Postal Code  ________

Mailing Address (only if different from above):

Position Title (e.g. Geologist, Manager, Student)_________________________________

Street/PO Address ______________________________________________ Suite/Apt. ______

City  ___________________________________ State/Country  ________ Postal Code ____

Other Information:

Phone No.  __________________________________ Fax No.  ___________________________

Email Address  ___________________________________________________________________

Do you prefer to receive your newsletters by email?       Yes            No   

Web site address  ________________________________________________________________

Last Degree Conferred ________ Year  ________  Major  _____________________________

University  __________________________________

Membership Status (check one in each row): New _______ Renewed ____ Reactivated ___    
					   Regular____ Student ____ Honorary ______

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For New Members Only:  

Date Submitted ________________      Date Approved ________________

PGS Sponsors (2) __________________________________________________________________

How did you find out about us? ____________________________________________________

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Attach Check for Dues. Regular members: $ 20.00 / Students: $ 5.00 Honorary: Gratis

Make check payable to: PITTSBURGH GEOLOGICAL SOCIETY 

To avoid delayed processing, return membership form directly to: 
John A. Harper
Pennsylvania Geological Society
400 Waterfront Drive
Pittsburgh, PA 15222-4745