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2010
WASHINGTON STATE HISTOLOGY SOCIETY
MEMBERSHIP APPLICATION

NAME:___________________________________________________HOME PHONE: (____)___________________

HOMEADDRESS:_______________________________________________________________________________

CITY: ____________________________________________________STATE: _________ZIP:__________________

EMPLOYER: _____________________________________________WORK PHONE: (____)____________________

WORK ADDRESS:_______________________________________________________________________________

CITY: ____________________________________________________STATE: _________ZIP:__________________

e-mail: (w)__________________________________________(H)______________________________________________

Permission to put your name and e-mail address for members only on WSHS website? Y N

Is this your first year of membership with WSHS? ______

I am enclosing $ ________ for the following:
____ $15.00 Annual Membership Fee
____ $28.00 Two-Year Membership Fee
____ $5.00 Student Membership (Accredited Histotechnology Programs only)

Please make checks payable to:
WSHS c/o Rita Ohara
9617 140th St. NW
Gig Harbor, WA 98329
For more information, just email: ohararm@hotmail.com