ESSO Grotto

Eastern States Speleological Organization, Inc.

Membership Application Form

Date: ________________

Name: _____________________________

Mailing Address: _____________________________________________

City/State/Zip: ______________________________________________

Email Address:________________________________________________

Telephone Contact Number: ____________________________________

Membership Dues:

Individual Member (Voting) $15 a year

Family Dependent (Non Voting) $5 per dependent / per year

Family Dependent Name: _______________________________________

Family Dependent Name: _______________________________________

Family Dependent Name: _______________________________________

Family Dependent Name: _______________________________________

Dues Expire on January 1st of Each Year

Make checks Payable to ESSO Grotto

Mail Completed Form and Payment to:

ESSO Grotto

c/o Sheila Gilliam

211 Woodland CT

Grayson, Kentucky 41143-8001