PNW-ISA Membership Form

I'd like to join. Sign me up for:

_______ PNW Chapter and ISA Membership ($155)

_______ PNW Chapter Only Membership ($60)

_______ Student Membership ($25)

_______ PNW Life Membership ($600)

_______ Sustaining Membership (circle one)*:    $250   $500   $1,000

__________ Amount Enclosed

Note: Amounts expressed in U.S. dollars. We do accept Canadian funds; please call the office for the current exchange rate.

*Sustaining Membership dues are tax deductible for U.S. residents.

Member Information

Name: ______________________________________________________

Company/Agency: ____________________________________________

Street Address: _______________________________________________

City: _______________________________________________________

State/Province: ____________________ Zip/Postal Code: ______________

Phone: _________________________ Fax: _________________________

E-Mail: ______________________________________________________

Method of Payment (circle one:)

Visa   MasterCard   Check

Card No.: _____________________________ Expiration Date: __________

Name on Card: ________________________________________________

Signature: ____________________________________________________