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2019 - 2020 Membership Renewal Form
Member Information
First Name
*
Last Name
*
Company Name
*
Mailing Address
*
Address Line 2
City
*
State
*
Alabama
Alaska
Arizona
Arkansas
California
Colorado
Connecticut
Delaware
Florida
Georgia
Hawaii
Idaho
Illinois
Indiana
Iowa
Kansas
Kentucky
Louisiana
Maine
Maryland
Massachusetts
Michigan
Minnesota
Mississippi
Missouri
Montana
Nebraska
Nevada
New Hampshire
New Jersey
New Mexico
New York
North Carolina
North Dakota
Ohio
Oklahoma
Oregon
Pennsylvania
Rhode Island
South Carolina
South Dakota
Tennessee
Texas
Utah
Vermont
Virginia
Washington
West Virginia
Wisconsin
Wyoming
Washington DC
Zip Code
*
Phone
*
Alternate Phone
Email Address
*
License #
Mark all that apply:
*
Pump Installer
Water Well Driller
Water Well Drilling Rig Operator
Heat Exchange Driller (or Heat Exchange Drilling Rig Operator)
Plumbing License:
Plumbing License:
Membership Renewal Level
Full Membership: $150
Licensed Water Well Driller or Pump Installer
Full Membership
Associate Membership: $100
Supplier/Distributor
Manufacturer Rep
Scientist
Hydro-geologist
Employee (of a Full Member)
Technician
Manufacturer
Geologist
State Government Official
Family Member (of Full Member)
Engineer
Consultant
Health Official
Other
If other, please describe.
Website Advertising
Website Advertising
$180 = Large Banner Ad (336 x 280 pixels)
$120 = Small Banner Ad (336 x 135 pixels)
Printed Newsletter Options
$1,300 = Full Page Ad Full Year
$475 = Full Page Ad Single Issue
$850 = Half Page Ad Full Year
$250 = Half Page Ad Single Issue
$600 = Quarter Page Ad Full Year
$175 = Quarter Page Ad Single Issue
Donations
Scholarship Fund:
Current Total:
$0.00
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