Print out and complete this application, and mail to
the address shown at the top of the form.

         M E M B E R S H I P  A P P L I C A T I O N

                  PATACS Membership
                    4628 Valerie Ct.
	     Annandale, VA 22003-3940
               
              Information phone number:  (703) 370-7649
	   Information email: info@patacs.org

	Dues-$30 (US) yearly (add $15 for non-US addresses)
          Please mail check with application to above address.

(  ) New / 1 Year Member   (  ) Address Change  (  ) Renewal


First Name:________________________________ Initial: ____

Last Name:_____________________________________________________

Mailing Address:________________________________________________________

                 _____________________________________________________________

City:_____________________________________

State:______ZIP:__________________

Telephone: (Home)(______)_______________________________________

(Work)(______)__________________________________________________


E-Mail Address: ________________________________________________

From what source did you hear about PATACS (Internet, member's name, etc.)?

________________________________________________________________