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IVETA Membership |
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IVETA Membership |
| (Please print or type all information) | ||||||
| Name: Last | First | Middle |
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| Title | ||||||
| Organization | ||||||
| Street address | ||||||
| City | State | Zip | ||||
| Country | ||||||
| Telephone no. | ||||||
| Electonic mail | ||||||
| Fax no. | ||||||
| Internet Address | ||||||
| Areas of interest (List only three)
Areas of Expertise
|
You are invited to attach your |
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| Type of Annual Membership (check one) ___ New _________Renewal | ||||||
| Category of Annual Membership (check one) | ||||||
| ____ Regular (US $50) | ||||||
| ____ Student (US $25) | ||||||
| ____ Non-Profit Organization (US $300) | ||||||
| ____ For-Profit Organization (US $600) | ||||||
(Membership year: 1 Jan – 31 Dec) |
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| Term of
Membership (Check all that apply) ___ 2005 ___ 2006 ___ 2007 ___ 2008 ___ 2009 |
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Method of Payment |
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| Check or Money Order (send check or money order payable to IVETA in US funds to address at bottom of form) | ||||||
| Amount enclosed $ | ||||||
| Credit Card Payment | ||||||
| Amount authorized $ | ||||||
| Please charge my (circle one) VISA or MASTERCARD | ||||||
| Account no. | Expires ___/___ | |||||
| Type or print name as it appears on card | ||||||
| Authorizing signature of cardholder (must be
signed) |
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|
IVETA
Secretariat |
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