Arizona Geological Society
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Donations and Payment Form

This form has been designed to handle donations, meeting sponsorship, newsletter advertisements and publications sales. 

Please follow the instructions for each of these categories of payments.  If your payment is for more than one of these categories, please itemize the amounts paid for each in the comments section at the bottom of this form.  

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Donation

* Mandatory fields
*First name
ALL CAPS PLEASE - Example Format - JOHN
Middle Initial
Example Format - C
*Last name
Example Format - SMITH
*E-mail
Lower Case Please - Example Format - jsmith@aol.com
Alternative E-mail
Alternative e-mail to list in membership directory.
Company/University
Example Format - JOHN SMITH & COMPANY

Meeting sponsors and advertisers should identify their company.
*Position
Example Format - GEOLOGIST
*Mailing Address
Example Format - 300 SPRING DR, STE 3

Please provide only one mailing address.
Mailing Address (cont)
*City
Example Format - TUCSON
*State
Example Format - AZ
*ZIP
Country
Example Format - MEXICO

Only fill in this box for addresses located outside of the United States.
*Work Phone
Use following format (888) 888-8888
Home Phone
Use following format (888) 888-8888
Cell Phone
Use following format (888) 888-8888
FAX
Use following format (888) 888-8888
Website
Example Format - www.geomineinfo.com
State Registration #
Example Format - AZ 1111
AIPG CPG #
Example Format - 1111
*Total Amount ($USD)
Tabulate Totals from Each of the Selections Below.
Payment frequency
Donations
If donating to more than one fund, use comment section below to designate how you wish the funds to be apportioned.
Meeting Sponsorship
Before making a payment be sure to check with VP, Marketing to confirm the month you wish to sponsor is available. Enter the confirmed month in the blank above.
Comment
 

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