TENNESSEE HERPETOLOGICAL

 SOCIETY

MEMBERSHIP APPLICATION

 

Name                                                                                                                         

Address                                                                                                                    

                                                                                                                                   

                                                                                                                                   

Phone                                                                                                                       

Email                                                                                                                         

Institutional Affiliation                                                                                               

 

MEMBERSHIP CATEGORY (check one)

 _____Supporting                                                      $30.00

 _____Institution                                                          $25.00

 _____Family                                                             $20.00

 _____Individual                                                          $15.00

 _____Student                                                            $10.00

___Donation (Chadwick Lewis Memorial Scholarship Grant) Amount: __________

 

                                                Application Date: _________________

 

Return membership fee & form to:

Chris Simpson, Treasurer
Tennessee Herpetological Society
c/o TWRA
464 Industrial Blvd.
Crossville, TN 38555

Tel:  (931) 484-9571 or EMAIL the above information to:
Chris.Simpson@TN.GOV