Pacific Coast Shellfish Growers Association

PCSGA Membership Application and Renewal Form

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

Mr. Mrs. Ms. Dr.

*First Name:

Middle Initial:

*Last Name:

*Company or Organization:

Position/Title:

*Street Address:

*City:

*State/Province:

*Zip/Postal Code:

Country:

*Telephone:

Fax

*E-mail:

Web site URL:

List all Counties where you farm (by State):

*I am:

a new member

a re-newing member

*Membership Category:

Grower (See Growers dues schedule)

(Grower memberships are for shellfish producers only.)

*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)

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.

(Click once and wait for confirmation page)

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