| NAME___________________________________________________
ADDRESS________________________________________________
CITY,STATE,ZIP___________________________________________
COUNTRY________________________________________________
EMAIL ADDRESS___________________________________________
TELEPHONE______________________CELL_____________________
SPECIAL INTERESTS________________________________________
________________________________________________________
VOLUNTEER/SPECIAL HELP INTERESTS________________________
________________________________________________________
ANNUAL MEMBERSHIP LEVEL (IN US DOLLARS):
BASIC INDIVIDUAL $10 ______ OTHER:_________________
FAMILY $50 ______ _______________________
AMIGO $100 ______ _______________________
AFICIONADO $500 ______ _______________________
AJAW $1,000_____ _______________________
PAYMENT METHOD: ___ CHECK ___VISA ___MC
NUMBER _______________________________ EXP _________
SIGNATURE __________________________________________ |
