Mineralogical Association of SA: Membership form

Mineralogiese Assosiasie van Suid Afrika
PO Box/Posbus 21290
HELDERKRUIN, 1733
Tel: (011) 958-1245

email: mwjillr@mweb.co.za
www.minsoc.org.za

I wish to become a
Ek wil graag aansluit as

	Member Lid	Membership Fee/Lede Geld R20
	Associate Member Assosiaat lid	R30
	Student Member Studentlid	NIL
	Associate Student Member Assosiaatstudentlid	R5

of the Mineralogical Association of South Africa and
van die Mineralogiese Assosiasie van Suid Afrika en

enclose R_________ as membership fee for this year
sluit R_________ as lidmaatskalfoie in vir hierde jaar

(cheques made payable to MINSA)
(tjeks betaalbaar aan MINSA)

NAME/NAAM: .........................................................................................

ADDRESS/ADRES: ..........................................................................................

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Email Address: .....................................................................

SIGNATURE/HANDTEKENING: ...................................................

DATE/DATUM: ..........................