Request for Life Membership

* First Name

Middle Name

* Last Name

* Address Line 1

Address Line 2

* City

* State

* Zip Code

Date of Birth

I hereby petition the ASHE Harrisburg Section Board of Directors to consider my request for exemption from
paying further dues. I understand that as a non-dues paying Member, I shall be known as a Life Member, but
this term shall not be used as a separate grade of membership. I am currently a Member in good standing of the
ASHE Harrisburg Section.

To the best of my knowledge, I meet the following criteria (kindly check only one):

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