Membership Registration

July 1, 2019 to June 30, 2020

Please complete this form designating your choice/choices of membership:

Name___________________________________________________________________________________

Address_________________________________________________________________________________

               _________________________________________________________________________________

               ____________________________________________________________ Zip__________________

Phone    _____________________________________________ email_______________________________

Birthdate____________________________________________ Retired from       School District

_______ PASR Snyder County Chapter @ annual membership of $10.00_ $                                                                                                                                            _

_______ PASR State @ annual membership of $60.00_ $                                                                                                                                            _

_______ PASR State Life Membership @ $700.00 $                                                                                                                                            _

                                                                                                                                       TOTAL           $ _______