Panama Canal Society, Inc.
7985, 113th Street,  Suite 334, 
Seminole, Florida 33772-4787
Questions? Call Toll Free 1-866-726-2262 
                                             
                                                                 
MEMBERSHIP APPLICATION                                           

New Members $30.00 Annually per family including children under 18 years
of age, plus a $10.00 Administrative Fee for new members and individuals 
who have not renewed their membership prior to February 1 of the current dues 
year shall be considered a new member and, as such, must pay the Administrative
Fee of $10.00.  Total: $40.00.                           


Renewals - $30 Annually (January 1 - December 31) per family, including
children under 18 years of age.  (A portion of this amount is for subscription
to the "Canal Record" for one year.
                                                                

Member Name:                                                     
____________________________________________________________     
Last                    First                                    
____________________________________________________________     
Nickname (If Desired)     Maiden Name                            
                                                                 
Spouse Name:                                                     
____________________________________________________________     
Last                    First                                    
____________________________________________________________     
Nickname (If Desired)     Maiden Name                            
                                                                 
Mailing Address:                                                 
____________________________________________________________     
Street and/or Box Number                                         
____________________________________________________________     
City                                                             
____________________________________________________________     
State           Zip Code                                         
                                                                 
Phone: (    )_____________  Applicant over 18? ___Yes ___No      
        Area    Number                                           
                                                                 
School Attended?                                                 
Applicant: ____BHS ____CHS  Year Graduated? ________             
                                                                 
Spouse:    ____BHS ____CHS  Year Graduated? ________             
                                                                 
CZ/PC Affiliation:                                               
(Mark X in appropriate box and IF RETIRED, PLEASE INDICATE YEAR) 
                                           MEMBER    SPOUSE      
                                         (X)Ret/Year (X) Ret/Year
Employee-CZ/PC.......................... __  ______  __   ______   
                                                                 
Employee-Military/Civilian.............. __  ______  __   ______ 
                                                                 
Employee-Contractor (US Government Only) __  ______  __   ______ 
                                                                 
Employee-Shipping....................... __  ______  __   ______ 
                                                                 
Dependant of Employee (See Next Line)                            
                                                                 
Parents Name and CZ/PC Affiliation _____________________________ 
IF CHECK IS NOT MADE ON U.S. BANK, MAKE PAYMENT BY MONEY ORDER   

(Revised 3/11/05 by W.P.McLaughlin)