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SRT Individual Membership Application

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Prefix            First Name               MI                       Last Name,                                 Suffix
Mailing Address:
City:
State/Province:	Postal Code:		Country:
Work Telephone		Fax  Telephone
Home Telephone:
E-mail Address (List only one):
Do you have a separate billing address?                No            Yes (If yes please list it on the back of this sheet)
Which mailings do you wish to receive?
All official member mailings (postal and email)		Postal member mailings only
E-mail member mailings only		None
Organization/Institution:
Type of Organization:
Title which best describes your position:
Membership Level  - (Membership will extend for 12 months from month after application receipt) ___ E-Member* US $5 Annually ___ E-Member Sponsorship*** US $10 Donation ___ E-Plus Member* US $15 Annually *For individuals in rural areas only. ___ Student** US $25 Annually ___ Individual US $35 Annually ___ Supporter US $125 Annually ** For individuals enrolled in accredited college-level, graduate or post-graduate studies. *** Sponsors two E-Members from rural areas for a period of 12 months each. ___ Benefactor US $250 Annually ___ Patron US $500 Annually
RATES ARE GIVEN IN U.S. DOLLARS. CHARGES TO YOUR CREDIT CARD WILL BE IN YOUR CURRENCY  AT THE EXCHANGE RATE IN EFFECT WHEN PAYING CHARGES.
Send Bank/Wire Transfer Bank:            Confirmation No:		_____Check ____ Money Order attached. Make check/money order payable Member name should be referenced on check/money order/wire transfer.
Please bill my:                       American Express                  MasterCard                             Visa
Card Number:		Expiration Date
Name on card:		Signature: