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Get Charles Sturm Treasurer American Malacological Murrysville Pa Form

THE AMERICAN MALACOLOGICAL SOCIETY Charles Sturm Jr. Treasurer American Malacological Society Inc. 5024 Beech Rd. Murrysville PA. USA 15668-9613 APPLICATION FOR NEW MEMBERSHIP IN 2012 CALENDAR YEAR PAGE 1 Please complete both pages of this form and mail it with your dues payment to the treasurer at the address above. THE AMERICAN MALACOLOGICAL SOCIETY Charles Sturm Jr. Treasurer American Malacological Society Inc* 5024 Beech Rd. Murrysville PA. USA 15668-9613 APPLICATION FOR NEW MEMBERSHIP IN 2012 CALENDAR YEAR PAGE 1 Please complete both pages of this form and mail it with your dues payment to the treasurer at the address above. First Name / Middle Initial / Last Name 1. CONTACT OPTIONS Please list my e-mail in the AMS Directory and contact me via e-mail to save time and money Please do not list my e-mail address in the Directory but contact me via e-mail Please use postal mail when corresponding with me 2. MEMBERSHIP CATEGORY Please check box and circle amount paid Regular Member - One year dues 2012 60. 00 105. 00 Each additional family member per year Student Member - One year 20. 00 Sustaining Member Regular dues plus 25. 00 85. 00 Affiliate Membership Shell Clubs other organizations Membership reinstatement/back issues 60 Regular / 20 Student for 2011. Members outside the US please note that there is a postage and handling fee for the Bulletin* 3. POSTAGE Canada Mexico 5. 00 per year 4. TAX-DEDUCTIBLE GIFT All other non-US addresses 10. 00 per year To Symposium Endowment Fund To Student Research Grant Endowment Fund TOTAL ENCLOSED Payment can be made by check drawn on a U*S* bank by international money order or by MasterCard/Visa* Make checks payable to the American Malacological Society. The AMS will issue a receipt and/or confirm membership status on request to csturmjr pitt. edu If you wish to make payment via VISA or MasterCard please complete the following VISA MASTER Card number Expiry Date Signature of cardholder Please provide your address and contact details on page 2 PAGE 2 ADDRESS AND CONTACT DETAILS Please fill in this form and mail it to the treasurer together with the first page. This information will be included in the annual AMS membership directory. For options see under 1 on page 1 TITLE DR MR MS* ETC NAME FIRST/INITIAL/LAST ADDRESS 1 Department Hall or box Institution Mailing address City State or Province Postal/ZIP code Country Office phone Home phone Cell phone For official use only Date r cd Paid to Comments Fax E-mail 2 Interests 3 Members may only provide a single address which will be published in the AMS membership directory. Students are advised to give the address of their institution to facilitate mail forwarding. Please give a work or institutional e-mail address where possible site s here. Murrysville PA. USA 15668-9613 APPLICATION FOR NEW MEMBERSHIP IN 2012 CALENDAR YEAR PAGE 1 Please complete both pages of this form and mail it with your dues payment to the treasurer at the address above. First Name / Middle Initial / Last Name 1. CONTACT OPTIONS Please list my e-mail in the AMS Directory and contact me via e-mail to save time and money Please do not list my e-mail address in the Directory but contact me via e-mail Please use postal mail when corresponding with me 2.

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