Washington Map Society

Membership Application / Renewal Form

Please printout this form on your printer.                                                             OK to Publish in
                                                                                                                       Membership Directory

Name_____________________________________________________                 __Y __N

Address___________________________________________________                  __Y __N




Home Telephone____________________________________________                __Y __N

Work Telephone____________________________________________                 __Y __N

Cell Phone_________________________________________________                __Y __N

E-Mail____________________________________________________                __Y __N

Also, please see the Membership Census Form for additional questions. The form is optional but your participation is appreciated!

   $ ___________ DUES (see rates below)
                                 Differences reflect mailing costs for The Portolan.
                                 United States:              $45 for 1 year; $85 for 2 years; $120 for 3 years
                                 Canada:                       $50 for 1 year; $95 for 2 years; $135 for 3 years
                                 Rest of the World:        $65 for 1 year; $125 for 2 years; $180 for 3 years

   $ ___________ Tax Deductible Contribution to support The Portolan and other projects (thank you!)

   $ ___________ Total     Pay this amount using or mail your check, payable to the Washington Map Society, and this form to:

John W. Docktor
3100 N Highway A1A PHA1
Fort Pierce FL 34949-8831