========================================================================== INTERNET SOCIETY 24 Feb 1994 Application for Individual Membership - Template __ Please enroll me as an individual member of the Internet Society. I understand that membership in addition to fostering the evolution of the Internet and its use, entitles me to receive the quarterly Internet Society News, reduced fees for attandance at Internet Society conferences and other benefits. Membership will extend for 12 months from the month of application receipt. I am applying for: __ Individual membership at $35.00 __ Student individual membership at $25.00 __ Please send me additional information on the Internet Society Name: __________________________________________________________ Postal Address: _________________________________________________ _________________________________________________ _________________________________________________ Internet Email address: _________________________________________ Fax (optional) : ____________ Telephone (optional): _____________ Payment Information: Payment of annual dues may be made by check, money order, credit card or wire transfer. ___ Payment is included with this application __ Please bill me For credit card payments: __ VISA __ Master Card __ AMEX __ Diner's Card __ Carte Blanche Card Number: ____________________________ Expiration Date: ____________________________ Signature: ____________________________ Send wire transfers to: Riggs Bank of Virginia Bank ABA number: 056001260 8315 Lee Highway Account number: Internet Society 148 187 10 Fairfax VA 22031 USA Please send by post, fax or email to: Email: Fax: +1 703 620 0913 (until 12 Mar) Fax: +1 703 648 9887 (after 12 Mar) Tel: +1 703 648 9888 (until 12 March 94) (after 12 March 94) Internet Society Internet Society 1895 Preston White Dr 12020 Sunrise Valley Dr #270 Reston VA 22091 Reston VA 22091 USA USA Form 94-001 v.1.1 ==========================================================================