________________________________________________________________
MEMBERSHIP APPLICATION
For the Fiscal Year June 1, 2011 – May 31, 2012
Please PRINT all information just as you wish it to appear in the Membership Directory
Please make out your check to PNHA
Charlie Szoch
_______________________________________________________________________________
( ) New
(
) Renewal
$20.00 PAYMENT ENCLOSED (Make checks payable to PNHA)
LAST NAME _________________________________ FIRST NAME _________________________________
SPOUSE
FIRST NAME __________________________________
If this is a renewal and the following information is the
same as last year, you may leave the following blank
or just fill-in
whatever has changed. In addition,
please provide the last
four digits
of your nine digit zip code.(e.g., 17222-9446)
HOME ADDRESS ___________________________________ZIP CODE Last Four Digits_________________
PHONE ____________________ E-MAIL ADDRESS __________________________________
Others,
including school age children, permanently at this address (for the Membership
Directory)
LAST NAME _____________________________ FIRST NAME ____________________________
LAST NAME _____________________________ FIRST NAME ____________________________
LAST NAME _____________________________ FIRST NAME ____________________________
LAST NAME _____________________________ FIRST NAME ____________________________
_______________________________________________________________________________
Membership Directory Options
( ) I do not wish to be listed in the hardcopy Membership Directory.
( ) I do not wish to be listed in the Membership Directory on the PNHA Web site.
( ) I do not wish my e-mail address to be listed in the Membership Directory or PNHA Web site.
Newsletter Delivery Option
( ) I want to have my PNHA Newsletter delivered via email.
(Please provide your email address above and circle which format you prefer to receive
the Newsletter – MS Word or PDF.)