TENNESSEE HERPETOLOGICAL

 SOCIETY

MEMBERSHIP APPLICATION

Name                                                                                                                         

Address                                                                                                                    

Phone                                                                                                                       

Email                                                                                                                         

Institutional Affiliation                                                                                               

MEMBERSHIP CATEGORY (check one)

 _____Supporting                                                      $30.00

 _____Institution                                                          $25.00

 _____Family                                                             $20.00

 _____Individual                                                          $15.00

 _____Student                                                            $10.00

___Donation (Chadwick Lewis Memorial Scholarship Grant) Amount: __________

                                                Application Date: _________________

Return membership fee & form to:

Chris Simpson, Treasurer

Tennessee Herpetological Society

c/o TWRA

464 Industrial Blvd.

Crossville, TN 38555