National Italian American
Sports Hall of Fame
Pittsburgh Chapter
Membership Application

 Approved by:
Date (MM/DD/YY): / /
All fields marked * are required
*Name
*Home Street Address
*City
*State
*ZIP
*Home Phone
*Company Name
*Business Name
*Address
*City
*State
*ZIP
*Business Phone

Additional Contact Info
Fax
*E-mail
Spouse Name
*Children
*How long have you lived in the community?
*Sponsor Name
*Are you willing to serve on a committee?

Yes No

*Signature: Date (MM/DD/YY): / /
*Presented on: (MM/DD/YY): / / Approved on:(MM/DD/YY): / /
Dues: $40.00 for your annual membership and donor listing in our banquet book.

Please list below how you want your name listed, i.e.;
Mario Andretti, Chip Ganassi, Tommy Lasorda
*Your Name:

Make Check Payable to:
Pittsburgh Chapter NIASHF
Anthony J. DiNardo
Member Chairman, NIASHF
113 Mitchell Drive
Pittsburgh, PA 15241