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ESTMIM  Membership Application
PLEASE SEE IMPORTANT INFORMATION BELOW FORM
& Fill out form completely

Title:
First name, initial:
Last name:
Company / institution:
Street address:

City:
State:
Zip or postal code:
Country:
How did you
hear about us ?

If other, please enter it below:
E-mail address: @
Voice phone: ( ) Ext.
Fax:

( )

Please indicate the membership level you would like to have.

 

 Family Membership: $50.00 /year

 Single Membership: $35.00/year
(No Family or Guest Privileges)

Associate Membership $35.00
(Over 35 Miles Or More Away From ESTMIM)
ESTMIM is always looking for volunteers to help with it's many projects and during our programs.  Please indicate anything you would be willing to give us a hand with.  No experience is required.

 

IMPORTANT:
Please send check payable to ESTMIM:

 ESTMIM Membership
Richard Potter
547 Tompkins Street
Syracuse NY 13204

ALSO:
PLEASE ENCLOSE WITH CHECK, YOUR CORRECT MAILING ADDRESS FOR FLYERS
AND A SELF ADDRESSED STAMPED ENVELOPE SO YOUR MEMBERSHIP CARD MAY BE SENT TO YOU.

 

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