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MEMBERSHIP APPLICATION FOR THE NORTHERN VIRGINIA MINERAL CLUB, INC.

( ) Family  $20.00/year One address

( ) Individual  $15.00/year

( ) Junior $6.00/year, 10 through 18 years*  Birth Date______________  

                                    *Under 16 sponsored by adult member.

( ) New ( ) Renewal      DUES are for Year_____________

ANNUAL DUES PAYABLE BY JANUARY 1st  

Pay at meeting or mail to:
                                                Northern Virginia Mineral Club
                                                c/o Richard Reiber, Treasurer
                                                2121 Marlboro Drive
                                                Alexandria, VA 22304

Name(s)_______________________________________________________________________

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Include First names of all family members and birth dates of all under 18 years of age.

Name/Birth_____________________________ Name/Birth_______________________________

Name/Birth_____________________________ Name/Birth_______________________________

Address___________________________________ Phone Home or Work____________________

City_____________________________________ State____ Zip_____________

Email(s) ________________________________________________________________________

Club membership list.
( ) Check here if you do not want your phone number and/or address included on club membership list.
( ) Name only…
( ) Other Please be specific.
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