Mail To:

Maine Herpetological Society 
99 Water Street 
Millinocket, ME 04462
Please Check One:

[__] $8 Student [__] $10 Individual [__] $15 Family [__] Renewal [__] Change of Address


Date: _____/_____/________

Name: _____________________________________

Phone: (______) ___________________________ 


Address: __________________________________

City:______________________________________

State:____________________ Zip:____________


Email:_____________________________________


Special Interests: ______________________________________________________________

_________________________________________________________________________________

_________________________________________________________________________________

_________________________________________________________________________________


(This information will be used in the membership directory. Feel free to include
anything you think other members may find helpful)

Please do not included the following in the directory:

	[__] Name [__] Address [__] Phone

Make check or money order payable to: Maine Herpetological Society

Thank you!