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Application for Membership

New Membership Dues $100.00

Renewal of existing membership is $100.00

Note - New Mailing Address!

AGEG
P. O. Box 1248
Dallas, GA 30132

Name ___________________________________________________________________________

Address _________________________________________________________________________

City __________________________________________ State _________________ Zip __________

Phone # ____________________________________________ FAX # ________________________

E-Mail ___________________________________________________________________________

Graduate of __________________________________________________________ Year ________

Embalmers License # __________________________________________________ State ________

Recommended by  1) _______________________________________________________________

2) _______________________________________________________________

Company Name ___________________________________________________________________

Address _________________________________________________________________________

City _______________________________________________ State _____________ Zip ________

Phone # ____________________________________________ FAX # ________________________

E-Mail ___________________________________________________________________________

Signature _______________________________________________ Date _____________________

REMITTANCE ENCLOSED:

New Active Member $100.00...................................................................$_________________________

(licensed embalmer)

New Associate Member $100.00............................................................$_________________________

(not a licensed embalmer, but actively employed in field of embalming)

Voluntary Contribution to Scholarship Fund.........................................$_________________________

Renewal of Dues $100.00..........................................................................$_________________________

Clinic $60.00..................................................................................................$_________________________

Non-Member Clinic Rate $175.00.............................................................$_________________________

Banquet $35.00 ............................................................................................$_________________________

TOTAL AMOUNT REMITTED........................................................................$_________________________

PLEASE COMPLETE THIS APPLICATION AND RETURN WITH PAYMENT TO:

Academy of Graduate Embalmers of Georgia

PO Box 1248

Dallas, GA 30132

www.AGEG.org

770-445-3180   Fax: 770-445-3893