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You are Cordially Invited . . . to Join The Ohio Academy of Science |
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MEMBERSHIP APPLICATION
Please print out, fill out and return with your payment to the Academy. Please Type or PRINT Check: ___ New ___ Renewal Circle title: Ms. Mrs. Mr. Dr. Prof. Name__________________________________ (First Middle Last)
Employer, organization, school, or institution _______________________________________ Department, Street or PO Box _______________________________________ City / State / Zip _______________________________________ Is this a home address? ____ Yes ____ No Ohio County_____________________________ Home (______) __________________________ Office (______) _________________________ FAX Number (_____)______________________ E-mail Address __________________________ FIELD OF INTEREST _______________________________________ Please Check Appropriate Line __ $1,000 LIFE (installment plan available) __ $1,000 Sponsor of the Academy __ $750 Sustainer of the Academy __ $500 Advocate of the Academy __ $500 Corporate Member __ $250 Supporter of the Academy __ $100 Institution, Organization or Agency Member __ $100 Friend of the Academy __ $85 Family (maximum of 3 persons) __ $75 Regular Member __ $40 Retired (age 59 & over) Member with Journal __ $40 College Student (under age 30) with Journal __ $40 Student (age 17 & under) with Journal __ $25 Retired Member without Journal __ $25 Student (age 17 & under) without Journal |
Method of Payment
___ Enclosed is a check made payable to The Ohio Academy of Science for $________
___ Please charge my credit card $________
NOTE: YOU MAY ALSO USE OUR ONLINE SITE AT: http://www.merchantamerica.com/ohiosci/
If paying by credit card, please PRINT your name as it appears on your card:
______________________________________ (First Middle Last)
___ VISA
___ MASTERCARD
Card Number (Be sure to include ALL digits)
____________________________________________
Exp. Date ___ | ___
Signature __________________________________
QUESTIONS? Phone (614) 488-2228 or outside of 614 area code, toll-free, if needed: 1-800-OHIOSCIence Fax (614) 488-7629
03/04/2008 |
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