========================================================================== INTERNET SOCIETY 1 May 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: ____________________________ Name on Card: ____________________________ 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 telephone toll-free or send by post, fax or email to: Email: Fax: +1 703 648 9887 Tel: +1 703 648 9888 Tel: 800 468 9507 (USA only) Internet Society 12020 Sunrise Valley Dr #270 Reston VA 22091 USA ----------------------- For Office Use Only Enrollment: Receipt: Date: By: Form 94-001 v.1.5 ==========================================================================