Application for Membership

National Association of State Land Reclamationists ATTN: Jeff Meitrott PA Department of Environmental Protection 186 Enterprise Drive Philipsburg, PA 16866

E-mail: Meitrott, Jeffrey jmeitrott@pa.gov

Memberships run from July 1 to June 30

Type of Membership:

There are four categories of membership in NASLR. (Please select)

State -- $200.00

Corporate Sponsor -- $200.00

Individual -- $10.00

Associate -- $10.00

Name Title

Agency or Company Address

City State Zip

Phone Fax E-mail

My Responsibilities lie in (check primary duty):

Inspection	Administration
Permitting	Technical Specialist
AML	Research
Consultant	Other

If you would like to contribute funds to the NASLR Educational Grant Program as a "business expense," please fill out the following form and return it with a check payable to National Association of State Land Reclamationists (NASLR), c/o Jeff Meitrott PA Department of Environmental Protection 186 Enterprise Drive Philipsburg, PA 16866

E-mail: Meitrott, Jeffrey jmeitrott@pa.gov

Amount of Contribution Name

Title Agency or Company

Address

City State Zip

Phone Fax E-mail