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Text File  |  1996-11-15  |  2KB  |  84 lines
  1. Internet Society
  2. Individual Membership Application 
  3.  
  4. Please enroll me as an individual member of the Internet 
  5. Society. In addition to being a significant contribution to 
  6. the evolution of the Internet and its use, membership 
  7. entitles me to a subscription to OnTheInternet magazine, 
  8. a subscription to the ISOC Forum (the Internet Society's
  9. organizational and informational electronic newsletter),
  10. reduced rates at Internet Society conferences, 
  11. and other benefits.
  12.  
  13. __  Individual Membership _ $35 Annually
  14.  
  15. __  Student Membership _ $25 Annually
  16.  
  17. Name
  18. Title
  19. Organization/Institution
  20. Postal Address
  21.  
  22. E-mail Address
  23. Telephone
  24. Fax
  25.  
  26. Please check the box that best describes your position:
  27. __  Owner/President/CEO/CIO
  28. __  Director/Manager
  29. __  Product Development Manager
  30. __  Systems Manager/Administrator
  31. __  Network Manager/Administrator
  32. __  Marketing/Advertising Manager
  33. __  Engineer
  34. __  Programmer
  35. __  Professor/Associate Professor
  36. __  Researcher/Assistant
  37. __  Librarian
  38. __  Consultant/Self-Employed
  39. __  Student
  40. __  Other
  41.  
  42. Please check the box that best describes your organization:
  43. __  Network Service 
  44. __  Software Company
  45. __  Information Systems Management
  46. __  Product Provider
  47. __  Educational Institution
  48. __  Nonprofit Organization
  49. __  Public or Private Library
  50. __  Publisher
  51. __  Other
  52.  
  53. Payment may be made by check, credit card, money order, or
  54. wire transfer. U.S. currency only.
  55.  
  56. __  Payment is enclosed.
  57.  
  58. Please bill my 
  59. __  American Express
  60. __  MasterCard
  61. __  Visa
  62.  
  63. Card No.
  64. Expiration Date
  65. Cardholder's Name 
  66. Signature
  67.  
  68. Send wire transfers to:
  69.  
  70. Internet Society Acct. No.148 38 710
  71. ABA No. 054000030
  72. Riggs National Bank of Virginia
  73. 950 Herndon Parkway
  74. Herndon, VA  20171
  75. U.S.A.
  76.  
  77. Send checks and money orders to:
  78.  
  79. Internet Society
  80. 12020 Sunrise Valley 
  81. Drive, Suite 210
  82. Reston, VA 20191-3429
  83. U.S.A.
  84.