The American Elasmobranch Society
AES Student Funding
American Elasmobranch Society
Standard 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 STANDARD MEMBERSHIP and requires endorsement by current member of AES.
Daniel S. Ha, AES Treasurer
1058 Cobblestone Lane
Lancaster, PA 17601-3368 USA
If you require additional information, Julie Neer can also be reached at:
dshaxx@verizon.net
Phone: 717-569-1061
Dues must be enclosed for Standard 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_____
Institutional Affiliation__________________________________________
Department_________________________________________________________
Mailing Address:
__________________________________________________________________
__________________________________________________________________
__________________________________________________________________
City __________________________ State ________________ Zip _________
Country_________________________________________________________
Telephone No.___________________ FAX No. ________________________
Electronic Mail Address: ______________________________________
Institutional Affiliation: ________________________________________
Department: ______________________________________________
RECOMMENDED BY: (Signature required): _________________________
Printed Name of Person Making Recommendation: ________________________
Affiliation of Person Making Recommendation: __________________________
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: _____ Mastercard _____ Visa
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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