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