# - Internet Society

Individual Membership Form


This form allows you simply and easily to apply for, renew, or amend your Internet Society membership. Please note that this page only works if your browser supports forms.

If you cannot or do not want to use this form, you may alternatively obtain an application template which you can complete and send yourself by fax (+1 703 648 9887) or email (membership@isoc.org).

In addition to fostering the evolution of the Internet and its use, membership provides the Internet Society publication, reduced fees for attandance at Internet Society conferences and other benefits. Membership will extend for 12 months from the beginning of the month of application receipt.


This is a form for: New Membership
                    Renewal
                    Renewal and Information Update


If you are presently an Internet Society member and using this form for renewal or update of information,
please enter your member number and family (last) name.

   MEMBER NUMBER:  
     FAMILY NAME:  

Regular Individual membership at $35.00
Student individual membership at $25.00

Is this membership for a Library? Yes No
    Are you a member of the Press?Yes No


As a member, do you:  Wish to receive all official member EMail and post mail materials
                      Wish to receive only official post mail materials; and no EMail
                      Wish to receive no mailings of any kind


                   Mr Ms Mrs Dr Prof M Prof Dr Dip Ing Ing Rev Miss Mlle
First Name:        
Init./Middle Name: 
Family Name:       
                   sr jr II III PhD 

Your title:        
Your affiliation:  
Your address:      
                   
City:               
State or Province:  Postal Code: 
Country:           

Tel (work) Number: Tel (home) Number: Fax Number: EMail address:


Payment

All payments must be in United States Dollars.

Please indicate the payment you wish to make:

 US$ 35 (Regular Individual Membership)
 US$ 25 (Student Individual Membership)

How would you like to pay?

  1. CyberCash Secure Payment Service
    The Cybercash Secure Payment System will encrypt your financial credit
    card information for private transmission over the 'net. To make
    use of Cybercash, you will need to download a free "wallet" client
    program (currently available for MS Windows and Macintosh). If
    you need a client, please click here.


  2. First Virtual Internet Payment Service
    The First Virtual Internet Payment System enables Information
    Commerce with simple, secure financial transactions. To pay using
    First Virtual, you must first join.


  3. Credit Card.
          Mastercard
          Visa
          American Express
    
    Credit Card or First Virtual Account Number: 
    
    For credit cards only:
         Expiration Date:    
         Name on Card:       
         Do we have your authorization to charge the indicated total 
         against your card number?  (Type YES) 
    

  4. Wire Transfer
        Riggs Bank of Virginia     ABA number: 054000030
        950 Herndon Parkway        Account number: Internet Society 148 387 10
        Herndon, VA  20171
        USA
    
        Please Indicate your name on the wire transfer
    
    

    To submit this form and provide information or pay as indicated

    Push the following to automatically email to (membership@isoc.org) :

    If you want to terminate this session, push the following:

    Thank you.


    members@isoc.org