*** Please print this membership application. ***
If you are unable to print this form, just copy the information, or
if you'd prefer a nicer layout, without the self-mailer, print
this one (pdf file).
Please make check payable to VdGSA in U.S. currency,
or provide credit card information
(card number and expiration date, Mastercard and Visa only).
Send to: VdGSA, K. Perlow Treas., 131 S. Humphrey Ave.,
Oak Park, IL 60302 (USA).
Membership rates:
| First-time members in the US & Canada -- $20 |
Residents of the US & Canada (renewing) -- $30 |
| Residents of all other countries -- $35 |
Students in the US & Canada (renewing) -- $25 |
Back to Membership
(fold forward)
-----------------------------------------------------------------------------------
Name: _________________ _______________________________
First Name Last Name
Mailing Address: ___________________________________________________
Street
____________________________ _____ ____________
City State Postal code
Telephone Number: ________________________ Fax: ____________________
E-Mail: ____________________________________
Institution (if student): ____________________________________
Donation: $_______ (Your additional contribution, which is
US tax-deductible, will help the Society
continue to provide quality programs.)
Indicate: Check (enclosed) MasterCard Visa
Card Number: _________________________________ Exp: ___________
Signature: ___________________________________________________
-----------------------------------------------------------------------------------
^^^^^ (fold back and seal) ^^^^^ PLACE
STAMP
HERE
< >
S VdGSA S
E Ken Perlow, Treas. E
A 131 S. Humphrey Ave. A
L Oak Park, IL 60302 L
< USA >
|
|