The American Elasmobranch Society
Membership
American Elasmobranch Society
Affiliate Membership Application
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 to AES Treasurer, Daniel S. Ha. This form is appropriate only for AFFILIATE MEMBERSHIP.
Daniel S. Ha, AES Treasurer
1058 Cobblestone Lane
Lancaster, PA 17601-3368 USA
If you require additional information, Daniel S. Ha can also be reached at:
dshaxx@verizon.net
Phone: 717-569-1061
Dues must be enclosed for Affiliate membership in one of the following categories (Check one):
- ___Student ($25.00) (NOTE: REQUIRES ENDORSEMENT OF FACULTY)
- ___Regular ($50.00)
- ___Foreign ($40.00)
- ___Family ($60.00)
- ___Associate ($100.00)
- ___Sponsor ($250.00)
- ___Patron ($500.00)
- ___Lifetime ($1,000.00)
- ___Benefactor ($1,000.00)
- ___Corporate ($5,000.00)
Total Enclosed (Annual Dues plus mail surcharge, if applicable) $ ______________
* All funds must be in U.S. currency, drawn on a U.S. bank or a New York bank draft, or by Mastercard of Visa (For credit card complete section below).
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. ________________________
E-Mail Address: __________________________________________________
Institutional Affiliation: _____________________________________________
Department: ____________________________________________________
IF STUDENT MEMBER, THIS MUST BE COMPLETED:
Degree Program (e.g. M.S. in Biology): _____________________________________
Name of Faculty Advisor: ________________________________________________
Signature of Faculty Advisor: _____________________________________________
Faculty Member Affiliation: ______________________________________________
CREDIT CARD PAYMENT: _____ Visa _____ Mastercard
Name as it appears on card: __________________________________________
Credit Card Number: _______________________________________________
Expiration Date: ___________________________________________________
Three digit code (from back of card): _________________________________
Signature: ________________________________________________________
Revised: 10/31/07
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