alphatau.gif (2007 bytes)ESP Membership
Application/Renewal Form

Print this form, fill in the requested information, and mail it with your payment to the treasurer's address listed at the bottom of this form.

Your Name:________________________________________ 
Title:_____________________________________________
Mailing Address____________________________________
City:____________________________   State:_______  Zip:________________
E-mail address: ____________________________________

___  Check here if this is a change of address.

Extension Region (check one):

___ Central ___ Lincoln University
___ East Central ___ UMC Campus
___ Northeast ___ UMKC Campus
___ Northwest ___ UMR Campus
___ Southeast ___ UMSL Campus
___ South Central ___ Retired
___ Southwest  
___ West Central

Desired membership (check one):

___ New member = $65 ($40 national, $20 chapter, and $5 one-time fee for
             new-member materials and initiation).
___ Continuing member = $60 (annual dues: $40 national, $20 chapter)
___ Returning inactive member = $60 (annual dues: $40 national, $20 chapter)
___ Life Member (retirees only) = $250 (one-time fee: $200 national, $50 chapter).

Make all checks payable to Epsilon Sigma Phi and return payment and application form to:

        Bob Schultheis
        ESP Treasurer
        Webster County Extension Center
        800 S. Marshall St.
        Marshfield, MO  65706

Last Revised: 2007-07-23