HOUSTON GELOGICAL AUXILIARY
REGISTRATION FORM

You are invited to become a member of
THE HOUSTON GEOLOGICAL AUXILIARY
dues are $20.00

Please make a check payable to the HOUSTON GEOLOGICAL AUXILIARY and mail with completed form to: HGA, Betty Alfred, 7915 Twin Hills Drive, Houston, TX 77071-1325

Last Name:_______________________________________

First Name:_______________________________________

Name Tag:_______________________________________

Spouse Name:_______________________________________

Name Tag:_______________________________________

HGS Member Company:_______________________________________

Home Phone:_______________________________________

Business Phone:_______________________________________

Business Fax:_______________________________________

Street Address:_______________________________________

City:_______________________________________

Zip:_______________________________________

Birthday (Month / Day only):_______________________________________

Email address:_______________________________________

Home fax:_______________________________________

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