Membership-form

MEMBERSHIP APPLICATION Membership # ____________

First Name ___________________________ Last Name ______________________________

Address ______________________________________________________ Apt. #_________

City __________________________________ State ________________ Zip_____________

Country of Origin (Optional) ____________________ Profession: _______________________

Would you like to volunteer your professional services to SHESO? (YES) (NO)

Telephone (Home)_______________ ( Work) ____________ Email _____________________

Spouse Name ______________________________ Profession ________________________

Children's Names & Dates of Birth:

1. ____________________________ DOB_______ 4. _____________________ DOB ______

2. ____________________________ DOB_______ 5. _____________________ DOB ______

3. ____________________________ DOB_______ 6. _____________________ DOB ______

I certify that the above information is correct, and I have read the membership articles of the
SHESO Constitution and Bylaws.

Signature _________________________________

1 Year Membership Dues: Family $180.00, Single $120.00, Student $60.00 (Evidence of FULL time
registration in educational institution is required); Multi-year Dues ~ 3-Year Membership: family
$500.00, Single $300.00.