Please return this form with your payment to:
PSP-HEMC
187 East Hershey Park Dr.
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
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
Account No
.
Exp. Date
Signature ____________________________________________________________________
I am Interested in volunteering for the PSP-HEMC
Mail to:
PSP-HEMC
187 East Hershey Park Dr. Hershey, PA 17033
Fax to
: 1-717-534-0771 or Call to place order by card: 1-717-534-0565
