Mother Lode Mineral Society

Membership Application Request

 

NOTE: Some computer e-mail security systems may not let you submit this e-mail.. If not, please e-mail to: jennilong@sbcglobal.net

 

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Thank you for your interest in our club.

 

Please complete and submit the following information. We will send you a Membership Application

Form and Information about our Club by return mail.

 

Other ways to request information:

Write to us:	PO Box 1263, Modesto, CA 95353
Leave a message:	(209) 527-6277
Attend a meeting:	See Calendar for dates and places

Information will be held in confidence and will not be used for solicitation.

REQUIRED FIELD*

*First Name:
*Last Name:
*Mailing Address:
*City/ State / Zip:
*E-mail address:
*Telephone:

PLEASE ANSWER THE FOLLOWING:

 

THE BEST TIME TO REACH YOU IF WE NEED TO VERIFY INFORMATION:

Daytime, Evening or Either:

 

TYPE OF MEMBERSHIP YOU ARE CONSIDERING:

Single, Couple, Family

 

Is there a child in the household between the ages of 8 and 18 who would be interested in the Jr. Rockhound Club? (Yes or No)

 

Would you like to receive e-mails about the club activities in the future? Yes or No

 

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