Become an INOGA Member

2012 Membership Dues Statement

Please complete this form and send with check to:

INOGA, Attn: CJ Mayhew, Membership Chairman, 6508 S. Uebelhack Rd., Mt. Vernon, IN  47620

Company	_______________________________________________
Contact Person	_______________________________________________
Address	_______________________________________________
Phone	_______________________________________________
Cell Phone	_______________________________________________
E-Mail	_______________________________________________

Do you want information e-mailed to you?      YES       NO

Make checks payable to Indiana OGA.  Your 2012 dues are for January 1 – December 31.

Please check the one that applies to your Company:

Producer	_____		Pipeline	_____
Service/Supply	_____		Gas	_____
Geologist	_____		Engineer	_____
Attorney	_____		Other(Specify)	_____

2012 DUES   

2012 DUES               $75.00 per person (voting member, no limit on number per company)

                        $25.00 per person (additional non-voting member per Company)

Dues include membership to The American Oil & Gas Reporter Magazine

  ______   Yes, I would like to receive The American Oil & Gas Reporter Magazine

   ______   No, I would not like to receive The American Oil & Gas Reporter Magazine

(Multiple members from a company may become voting members if they choose to pay the full $75 membership fee; $3 of each paid membership goes directly into Scholarship Fund)

Extra Donation:   ______________

Total Enclosed:  ______________