System Safety Society

P.O. Box 70, Unionville, VA 22567

540-854-8630 ¨ 540-854-4561 fax ¨ email:

1998 ANNUAL RENEWAL NOTICE and DIRECTORY UPDATE

July 1, 1998 through June 30, 1999

Dear Society Member,

Your membership in the System Safety Society will expire on June 30, 1998. To renew, please update the data on this form for the membership directory and mail in, along with your check for «TOTAL», to the above address. To avoid a lapse in your membership, please submit by July 31, 1998.

Current Mailing Information Mailing Address Changes Only
Member Number «MBR»
«ADD_COMPAN»
«FIRST» «NAME»
«STREET», «RT_BOX» «SUITE»
«CITY», «STATE» «ZIP»
Email address:
Telephone Number:

Dues payment

CHECK VISA AMEX Mastercard
Card Number Expiration Date
Card Holder Name (please print)
Signature Amt. Remitted $

Membership Information

Professional Certification: PE CSP CHCM CHP CIH Other
Present Membership Classification: «STATUS» Update forms are available upon request

Do not show my home phone number in the SSS directory

Do not show my work phone number in the SSS directory

Do not show my name on any SSS mailing

I would like to volunteer for the following :

Comments:
Paid Receipt upon request