OCLRE Membership Application

Title
First Name
Last Name
Suffix
School/Organization:
School District (if applicable):
Title/Position:
Grade level(s):
Work Street Addr:
Work City:
Work State: Work Zip:
Work Phone: Work Ext:
Work Fax:
County:
OH House District: OH Senate
Home Street Addr:
Home City:
Home State: Home Zip:
Home Phone:
Cell Phone:
E-Mail checked most consistently:
My preferred address is: Work Home E-Mail
The best way to contact me is: Phone Fax Regular Mail EMail
OCLRE membership is individual and annual, effective September 1 of each year. Membership is $30 per academic year. Full-time college students are eligible for membership at a reduced rate of $15. College attending should be indicated above. Please choose your membership status/request:
OCLRE has several options for payment. You may pay with a credit card, request OCLRE to issue an invoice, or enter a purchase order (PO) number. If the PO number is not available, you may enter "pending".
Optional information
How did you hear about OCLRE?
Other organization (please specify)
Other (please specify)
Gender:
Race/Ethnicity:
   - denotes required fields