3899 North Front St., Harrisburg, Pa. 17110 · Phone: (717) 703-3000 · www.panewsmedia.org
JOURNALISM DEPARTMENT/SCHOOL
MEMBERSHIP APPLICATION
Date of Application: ______________________________
Name of School: ___________________________________________________________________________________________________________
Department Name: _________________________________________________________________________________________________________
Address: ___________________________________________________________________________________________________________________
City: _____________________________________________ State: __________ Zip: ________________ County: _______________________
Main Phone: _____________________________________________ Main Fax: _____________________________________________________
Website: ___________________________________________________________________________________________________________________
Department /School Email Address: __________________________________________________________________________________________
Department Chair Name: _____________________________________________ Title: _______________________________________________
Email Address: _____________________________________________________________________________________________________________
Department Phone: _______________________________________ Department Fax: _______________________________________________
(if different from above)
Key Contact: _________________________________________________________ Title: _______________________________________________
Email Address: _____________________________________________________________________________________________________________
ANNUAL DUES: $125
No payment is necessary at this time.
Authorized Signature: ______________________________________________________________________________________________________
Print Name: ________________________________________________________________________________________________________________
Please mail or fax this application to the address below.
For question, contact Mary Firestone, Manager Member Services & Meetings, at (717) 703-3069 or maryf@pa-news.org.
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