print this page and mail with payment to Dick Hartz (address at bottom of form)

FORSYTH GEM AND MINERAL CLUB, INC.

Winston-Salem, NC 27120

For the Year 2006

Membership Application

Date ______________

Member Name:______________________________________________________

Additional Family Names:

_______________

_______________

 _______________

_______________

 _______________

_______________

Address:____________________________________________________

                        Street                          City                                          State         Zip

Telephone     Home (____)__________________

                         Work (____)____________________

E-Mail Address ____________________

If you have an e-mail address, would you be willing to receive the bulletin via e-mail rather than hard copy?                     

Yes                          No

Annual Dues of $15.00 are payable January 1 for the current year, per family (mailing address). Dues are reduced to $8.00 per family, if joining after July 1 of the year.

I am interested in the following activities (check all that apply):

Mineral Collecting

Fossils Gold or Silver Smithing Lapidary Faceting Carving Jewelry Making Wire Wrapping

Other _____________

I would like to help with the Annual Gem and Mineral Show?   Yes     No

Circle yes or no

 Please complete and return to the Club Treasurer, Dick Hartz, at the below address.

 Additionally:   Have you received medical training i.e. Doctor, PA or RN?   Yes     NO

Dick Hartz

1028 Hartz Lane

East Bend, NC 27018                                                                                     __________

                                                                                                                                                _________