Classification Society of North America / Membership Form

Benefits of membership include:

We look forward to your continued membership and participation in CSNA.

------ Please complete the information below ------

DUES (circle the amount being paid):               2005   2006   2007 & beyond
                                                                  (per year)
Regular member (receive all publications)           $80    $80    $80
Retired regular member (receive all pubs)           $60    $60    $60
Student member (receive all pubs)- 2005 only        $20    xxx    xxx
For members of IFCS member societies:
  Affiliate member (receive J. Class. only)         $60    $60    $60

Renewal (have been a member before) _____      New Member application _____

(Please PRINT, at most 30 characters per line.)

Name                __  __  __  __  __  __  __  __  __  __  __  __  __  __  __  __  __  __  __  __  __  __  __  __  __  __  __  __  __  __

Address line 1 __  __  __  __  __  __  __  __  __  __  __  __  __  __  __  __  __  __  __  __  __  __  __  __  __  __  __  __  __  __

Address line 2 __  __  __  __  __  __  __  __  __  __  __  __  __  __  __  __  __  __  __  __  __  __  __  __  __  __  __  __  __  __

                         __  __  __  __  __  __  __  __  __  __  __  __  __  __  __  __  __  __  __  __  __  __  __  __  __  __  __  __  __  __

                                        City                                                              State/Province                   Postal Code

Country: _________________                                                       If change of  address,  check here:  _____

E-mail address(es): _________________________________     If change of e-mail address,  check here: ______

If a directory is published, would you like to be listed?  Yes _____     No  _____

Total amount of dues enclosed:  $ _________  For year(s): ________

I enclose a check (in U.S. currency only, drawn on U.S. bank), payable to the Classification Society of North America: ___

I am paying with a charge card: VISA: _____ MasterCard: _____

For charge card payments only:

Card Number: ___ ___ ___ ___ -  ___ ___ ___ ___  -  ___ ___ ___ ___  -  ___ ___ ___ ___  

Expiration date (mm/yy)  __ __ / __ __                  Authorization Signature: _______________________________

Please send by regular mail to:

CSNA Business Office
Prof. Stanley L. Sclove 
IDS Dept.  (MC 294)
University of Illinois at Chicago
601 South Morgan Street
Chicago, IL 60607-7124, USA  
Email:  slsclove@uic.edu
Fax:    312-413-0385
Voice:  312-996-2681
Sec'y:  312-996-2676

Note: Due to the lack of security, we do not recommend sending credit card numbers via email. Please print and mail with check (in U.S. currency only, drawn on U.S. bank), or send via fax. However, for your convenience, email sent at your own risk will be accepted.


D:\myfiles\CSNA\forms\mmbrshp\allpurpose\2004.doc                  Created    2003: Nov 10             latest revision   2004: Dec 3