MSSC Membership Request Form

Please provide the following information:

Note: Only the items in bold are required.

First Name
Last Name
Middle Initial
Other Family Members  (if Family Membership is requested)
Street Address
Address (cont.)
City
State	Alabama Alaska Arizona Arkansas California Colorado Connecticut Delaware D.C. Florida Georgia Hawaii Idaho Illinois Indiana Iowa Kansas Kentucky Louisiana Maine Maryland Massachusetts Michigan Minnesota Mississippi Missouri Montana Nebraska Nevada New Hampshire New Jersey New Mexico New York North Carolina North Dakota Ohio Oklahoma Oregon Pennsylvania Rhode Island South Carolina South Dakota Tennessee Texas Utah Vermont Virginia Washington Washington D.C. West Virginia Wisconsin Wyoming
ZipCode
Work Phone
Home Phone
FAX
E-mail
URL
Membership Type	Individual ($20.00 per year) Family ($30.00 per year)
Your Interests

Remember...Submitting this form does not make you an automatic member of the
Mineralogical Society of Southern California, Inc. Your membership application must
be accepted and dues paid.