LCCPASR/PASR Membership Form

(Please type or print)

Name ____________________________ Soc. Sec. # _______________

Address ___________________________________________________

City __________________________ State __________ Zip__________

Phone _______________

School District (retired from) ___________________________________

(Please check all appropriate)

PASR State Membership (Annual Dues $45.00 ___ Lifetime $500.00__)

Lycoming County Chapter (Annual Dues $10.00 ___ Lifetime $50.00__)

*NOTE: PASR Life Membership is payable in two, equal annual
installments: Pay $250 now and next year PASR will bill you for the
remaining $250.

Mail this completed form along with a check for the total amount.
Made Payable to "LCCPASR" and mail to:

Mrs. Carla O. Auten
1440 Rabbittown Road
Muncy, PA 17756