Pacific Coast Shellfish Growers Association

(Fields marked * are required. Please fill out one form per applicant.)

*I am: a new member a re-newing member

None Mr. Mrs. Ms. Dr. Other:

*First Name:

Middle Initial:

*Last Name:

Spouse:

*Company or Organization:

Department:

Position/Title:

*Street Address:

Address Line 2:

*City:

*State/Province:

*Zip/Postal Code:

Country:

County:

*Work Phone:

Extension:

Fax Number:

*E-mail:

*Confirm E-mail:

Web site URL:

I am an NSA member:

If Grower, please list all Counties where you farm by state, one per line:

	County:	State:
1.

(up to 12, please rank by highest to lowest harvest volume)

Select your primary growing region:

List your Certificate Number(s):

*Membership Category:

(Grower memberships are for shellfish producers only.)

	Grower (See Growers dues schedule)
Annual Farmgate Sales: $
	*Grower Payment Plan option preferred:
	Annually
	Bi-annually
	Quarterly
	Monthly

	Allied - Subscriber ($40) (See Allied dues schedule)
	Allied - Friend ($125)
	Allied - Associate ($275)
	Allied - Sustaining ($600)
	Allied - Corporate ($1200)
	Allied - Patron ($5000)
	If Allied: Broker/Buyer Industry Supplier

Annual Dues Amount:	$


*Amount Paid:	$ (Included with this application)

*Pay by:			Visa/Master Card online (Payment Button on next page)
			Visa/Master Card by Phone (Call 360-754-2744 between 8 AM and 5 PM Pacific time)
			Check by mail

Comments:

Please make checks payable to PCSGA and mail to:

The Pacific Coast Shellfish Growers Association
120 State Ave NE PMB# 142
Olympia, WA 98501

To pay by telephone, call 360-754-2744 between 8 AM and 5 PM Pacific time.

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(Submit button must be clicked to submit completed form. If you have problems with this form, please email postmaster@pcsga.org.)