Please return this form with your payment to:

PSP-HEMC
187 Police Academy Drive
Hershey, PA 17033 

**Complete this form then print and mail it**


PSP-HEMC Membership Form 
NAME

ADDRESS
CITY, STATE, ZIP
PHONE -
EMAIL ADDRESS

Please check the box next to the corresponding membership level you have chosen:

$30 Individual  $20 Senior (60+)
$60 Family $100 Supporting
$250 Association/Business $500 Corporate
$500 Sustaining $1,000 Benefactor
   Friends of HEMC
In lieu of a membership pledge, please except my donation of ........ $

My check made payable to the PA State Police-HEMC is enclosed
  
Please Bill my              Visa           Master Card        Discover
Account No.
Exp. Date 
 
Signature ____________________________________________________________________
I am Interested in volunteering at PSP-HEMC  






 
Mail to: PSP-HEMC 187 Police Academy Drive - Hershey, PA 17033 

Fax to: 1-717-534-0771 or Call to place order by card: 1-717-534-0565