American Elasmobranch Society

Membership Application

STANDARD

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. This form is appropriate only for STANDARD MEMBERSHIP and requires endorsement by current member of AES. 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):

____Student ($25) (NOTE: REQUIRES ENDORSEMENT OF FACULTY)
____ Graduate 3-yr renewal ($75.00)***
____ 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 $__________________

*student membership level only permissible using the standard membership category
**must sign terms of agreement below
***can renew membership for three years at the student rate the year you graduate
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of at least $250 or $275, respectively, are not received by AES (postmarked by January 1st), life membership will be rescinded, and the balance will be applied to standard or affiliate memberships at the person’s current membership level (i.e. student or professional).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: _______

Institutional Affiliation: ________________________________________

Department: ________________________________________________

Mailing Address: ___________________________________________

                         ___________________________________________

City: ___________________________________ State: _____________ Zip: ____________

Country: ________________________________

Telephone No. _________________________ Fax No. ____________________________

Electronic Mail Address: _________________________________________


RECOMMENDED BY: (Signature required) __________________________________

Printed Name of Person Making Recommendation: _______________________________

Affiliation of Person Making Recommendation: __________________________________


IF STUDENT MEMBER, THIS MUST BE COMPLETED:

Name of Faculty Advisor: ____________________________________

Signature of Faculty Advisor: _________________________________

Faculty Member Affiliation: __________________________________



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: ________________________________________________