Pinal Gem and Mineral Society
Membership Application
To join the Pinal Gem and Mineral Society, send copy of this application, along with required payment for dues to Pinal Gem and Mineral Society, 351 N. Arizona Boulevard, Coolidge, AZ 85128
Email questions to:
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Application Date: _ / __ / ___ [ ] Renewal [ ] New Member
Annual Membership Dues:
[ ] Junior (Under 18) {FREE} [ ] Adult (Senior) {$12.00} [ ] Family/Couple {$20.00}
Address Information: Please PRINT clearly and fill in all appropriate fields.
Last Name: ______First Name: ______
Address: ______Phone: ( ) - .
City: ______State: ______Zip: ______Email: ______
[ ] Sign Informed Consent Waiver of Liability Form to attend Field Trips and Activities? (Yes) or (No)
[ ] Are you able to receive email version of society Newsletter? (Yes) or (No)
[ ] Do you approve publishing your photo, address, email & phone number in Membership Roster? (Yes) or (No)
[ ] How did you learn about PGMS? ______
Volunteer Areas of Interest: (Check as many as apply):
[ ] Presentations [ ] Field Trips [ ] Museum [] Newsletter [ ] Website [ ] Society Officer [ ] Hospitality at Meetings
[ ] Gem & Mineral Show [ ] Committees [ ] December Holiday Party [ ] Newsletter Contributor [ ] Field Trip Chair/Assistant [ ] Educational Instructor [ ] Membership Chair/Assistant
Earth Sciences and Areas of Interest: (Check as many as apply):
[ ] Geology [ ] Mineralogy [ ] Gemology [ ] Lapidary [ ] Silversmith [ ] Meteorites [ ] Paleontology [ ] Archeology
[ ] Radioactive Minerals [ ] Fluorescent Minerals [ ] Faceted Gemstones [ ] Jewelry [ ] Micromounts [ ] Thumbnails
[ ] Miniature [ ] Cabinet Display Minerals [ ] Other (please indicate) ______
Pinal Gem and Mineral Society (PGMS) is an affiliate of the Artisan Village of Coolidge, LLC which is an organization of the Coolidge Performing Arts Center Foundation, Inc, a nonprofit, tax exempt 501c3 charitable organization. (www.coolidgeperformingartscenter.org)
*** Please check our website (www.PinalGemandMineralSociety.org) to verify Meeting Information. ***
______
For Treasurer:
Payment Rec’d: [ Y ] Cash: $______Check: $______Other: $______Specify ______
For Membership Chairperson:
Membership Card(s) sent: [ Y ] Current Newsletter sent: [ Y ] Society Roster sent: [ Y ] Data Based: [ Y ]
Liability Waiver Signed: [ Y ] or [ N ]