PRINT THIS FORM
The Dayton Underground Grotto
of the National Speleological Society
Membership Application Form
www.dugcaves.com

___________________________________
Date

__________________________________________________________________________
Name - Please print clearly

__________________________________________________________________________
Street

__________________________________________________________________________
City, State & ZIP

__________________________________________________________________________
Email Address

____________________________________
Telephone 1

_____________________________________
Telephone 2 (or emergency contact telephone number)

_____________________
NSS # (if member)

Method to Receive Carbide Courier Newsletter

circle one

PAPER

ELECTRONIC

I am 18 years of age or older.

circle one

YES

NO
Birthday - month and day only (optional) _____ / _____ / XXXX

Membership Types and Annual Dues:

_______ Individual ............................................ $15.00

_______ Individual - Student (Full time students only) ......... $7.50

_______ Family ...(list family members on back)................ $20.00
(Family members must reside in the same household)

Makes checks payable to the Dayton Underground Grotto.

Mail completed form and payment to: Alan Leach, 2217 Cleneay Ave, Norwood, OH 45212.

Note: Non-NSS members or members under 18 years of age cannot vote or hold a grotto office. One paper Carbide Courier Newsletter per address per month. DUG's membership year is October 1st through September 30th. Dues are prorated by fifty percent after March 31st. Last revised on 4/10/2007.