American Elasmobranch Society

Membership Application

Affiliate

The membership period is from January 1 to December 31 and is renewable on an annual basis.

Print a copy of this form and forward it and payment to AES Treasurer, Daniel S. Ha. All funds must be in U.S. currency, drawn on a U.S. bank or a New York bank draft, or by credit card (For credit card complete section below).

Daniel S. Ha, Treasurer AES
1058 Cobblestone Lane
Lancaster, PA 17601-3368

If you require additional information,
Daniel S. Ha can also be reached at:
treasurer@elasmo.org or
Phone: 717-569-1061

Dues must be enclosed for Standard membership in one of the following categories (Check one):

____	Regular ($50)
____	Foreign ($40)
____	Family ($60)
____	Associate ($100)	____	Sponsor ($250)
____	Patron ($500)	____	Benefactor ($1,000)
____	Corporate ($5,000)
____	Lifetime ($1,000)	____	¼ Lifetime installment ($250.00)*
____	Lifetime Family ($1,100.00)	____	¼ Lifetime Family installment ($275.00)*
Total Enclosed $__________________
*must sign terms of agreement below NOTE: any membership category can renew for multiple years

Lifetime membership payment terms of agreement: Lifetime memberships are offered by the American Elasmobranch Society for a total cost of $1000. This offer is available for any interested members and confers all member benefits in perpetuity. Life membership can be paid for with four annual payments of $250, and the balance may be paid in full at any time once a lifetime membership is initiated. Lifetime family memberships for any interested party and his/her spouse and children are additionally available for $1100 (or four payments of $275). If a lifetime membership or lifetime family membership is initiated but annual payments of at least $250 or $275, respectively, are not received by AES (postmarked by January 1st), life membership will be rescinded, and the balance will be applied to standard or affiliate memberships at the person’s current membership level (i.e. student or professional). There will be no refunds of partial payments of life membership.

I, ___________________________________ (please print name here) agree to these terms.

__________________________________________ (signature and date required here)

The AES newsletter and membership directory will be posted on the AES website. You will receive an email when they are available.

PLEASE PRINT

Last Name: _________________________ First Name: _______________________ Title: _______

Mailing Address: ___________________________________________

___________________________________________

City: ___________________________________ State: _____________ Zip: ____________

Country: ________________________________

Telephone No. _________________________ Fax No. ____________________________

Electronic Mail Address: _________________________________________

Institutional Affiliation: ________________________________________

Department: ________________________________________________

CREDIT CARD PAYMENT:

Mastercard Visa American Express Discover

Name as it appears on card: __________________________________
Credit Card Number: _______________________________________
Expiration Date: ________________________ Billing ZIP Code: ________________________
Three digit code (from back of card): ___________________________
Signature: ________________________________________________