PSP-HEMC Membership Renewal Form
  

NAME:

ADDRESS Line 1:

ADDRESS Line 2:

PHONE:

 -
CHANGE OF ADDRESS

ADDRESS Line 1:

ADDRESS Line 2:

PHONE:

 -    E-mail:

Please check the box next to the corresponding membership level you have chosen:
$30 Individual  $20 Senior (60+)
$50 Family $100-$499 Supporting
$200 Corporate/Business $500-$999 Sustaining
$1,000 Benefactor

My check payable to: PA State Police - HEMC is enclosed
  

Visa           Master Card       Discover
Card No.

 
Exp. Date:   /
    Month

Year
 
Signature:    ___________________________________________________________________________________

(For Credit Card use)

  I am Interested in Automatic Renewal

Please mail completed form to:

  
 
PSP-HEMC
187 E. HersheyPark Dr.
Hershey, PA 17033