2012 MEMBERSHIP APPLICATION

Date ________ Membership Year 2012    New    or  Renewal   ( please circle )

Contact  Name / Person _______________________________________________________

Institution / Company    _______________________________________________________

Address                          _______________________________________________________

City , State & Zip          _______________________________________________________

Phone   ______________    fax   _____________  email  _____________________________

Type of Membership                        New Member Fee & Renewal Fee                       Discount Renewal Fee

    ( Check one )                                        after March 30th                                                before March 30th

 

_____  Group                                                   $ 67                                                                        $ 62

_____  Full                                                       $ 23                                                                        $ 20

_____  Student                                                $   9                                                                         $  7

 

Membership is calendar based   ( Jan 1  - Dec 31 )

Make Checks payable to:  MEPCIS

Please print out and send completed application and check to:

Seth Lawall

1746 Michael Drive

Whitehall. Pa  18052

Additional  Members Names:   ____________________________________________________________

                                                   ______________________________________________________________

                                                  _______________________________________________________________

MEPCIS bylaws limit corporate / commercial groups to two voting members. Please list below.

1. _________________________________   2. ________________________________________

Keep up to date and visit MEPCIS web page at:  www.mepcis.com