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Northeast Chapter Colorado Oil & Gas Association P.O. Box 243 Fort Morgan, Colorado 80701
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Membership Application And/Or Scholarship Contribution
Name(s): _________________________________________________________
_________________________________________________________
Company: _________________________________________________________
Address: _________________________________________________________
City, State, Zip: ___________________________________________________________
Phone: _________________________________________________________
Fax: _________________________________________________________
E-Mail: _________________________________________________________
Are you a recipient of the Flo-Line Newsletter Yes____ No____
Any area of expertise that would benefit the chapter:__________________________
Levels of Participation: Scholarship Fund ContributionsIndividual/Member $25.00 Lyn Crumley Scholarship FundPlease designate Amount Corporate $120.00 Silver $100.00-$249.00 Includes up to 5 individual members Gold $250.00-$499.00 Platinum Corporate $230.00 and up Platinum $500.00 and up Includes up to 10 individual members***Please Designate how you would like Funds to be applied***
DUES Paid: ____________________________________ Scholarship Paid: ____________________________________ TOTAL: ____________________________________
Please Make Check Payable To and Mail to: NECCOGA P.O. Box 243 Ft. Morgan, Colorado 80701-0243 |