PSP-HEMC Membership Renewal Form
NAME:
ADDRESS Line 1:
ADDRESS Line 2:
PHONE:
-
E-mail:
CHANGE OF ADDRESS
NEW ADDRESS Line 1:
NEW ADDRESS Line 2:
PHONE:
-
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
Payment Method:
Check
Credit Card
My check payable to: PA State Police - HEMC is enclosed
Card No.:
Exp. Date:
/
(Month / Year)
CVV:
I am Interested in Automatic Renewal
Signature:
(For Credit Card use)
Please mail the completed form to:
PSP-HEMC
187 E. HersheyPark Dr.
Hershey, PA 17033