UPSTATE HERPETELOGICAL ASSOCIATION

MEMBERSHIP FORM – Please Print Clearly

Check all the apply

$20 Membership

$25 Contributing Member

$30 Business Member

(includes special listing in the directory)

First Class Option

(Newsletter sent 1^st Class, add $10.00 to your dues)

Change of Address

Renewal

New Membership

Date ___________________

Name____________________________________________ Phone (_____) ________________________

Mailing Address __________________________________________

E-Mail______________________________

City _______________________________________State _____________________ Zip____________________

Special Interests ______________________________________________________________________________

______________________________________________________________________________

This information will be used in the directory. Mail check Payable to:

Feel free to include anything you think other Upstate Herpetological Association

members may find helpful)

Mail to: Bob Cunningham

Referred by: MaxMan Reptile Rescue 409 Waldorf Parkway

Syracuse, NY 13224