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Membership Application

Mail this form with check to:
KYANA Geological Society, c/o David Horn
1702 Applewood Lane
Louisville, KY 40222.

Make check payable to:  KYANA Geological Society.   please print clearly.

name  _______________________________________________________________

address  ____________________________________________________________ 

city  ________________________   state   ___________   zip code ___________  

e-mail  ______________________________________________________________

phone:  Home (____) ____________  Business (____) ___________date _______
type of membership desired (due Jan 1st):   (   )  new    (   )  renewal
(   ) individual ($15.00)    (   ) student ($10.00)    (   )  family ($20.00, list names):

____________________________________________________________________________________ 

dues cover the period of Jan-Dec & include both KYANA & federation dues.

please check all areas that interest you or your family:

(    ) mineralogy	(    ) field trips	(    ) serve on a committee
(    ) fossils	(    ) study groups	(    ) social functions
(    ) lapidary arts	(    ) junior rockhounds	(    ) teach/presentations
(    ) gems	(    ) show committee	(    ) specimen auctions
(    ) crystals	(    ) swap sessions	(    ) other _______________
(    ) general geology	(    ) exhibiting	(    ) other _______________

Please let us know if you have any skills that you would like to share with the club    (leadership, accounting, computer skills, marketing, editing, etc.):
___________________________________________________________

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