Application for Membership To: Internet Society Please enroll me as a member of the Internet Society. I understand that membership entitles me to receive the quarterly Internet Society News, reduced fees for attendance at Internet Society conferences and other benefits. Membership privileges will be for twelve months from the receipt of payment. I am applying for ____ regular membership at $70.00 ____ student membership at $25.00 (please send proof of status) Name:_____________________________________________________________ Postal Address: _________________________________________________ _________________________________________________ _________________________________________________ _________________________________________________ Internet Address:_________________________________________________ ____ Please bill me. ____ Payment is included with this application as below. Payment Information: Payment of Internet Society annual dues may be made via check, money order, credit card or wire transfer. For credit card payments: Send wire transfers to: __AMEX __VISA __MC __DINERS __CARTE BLANCHE Bank: Riggs Bank of Virginia Merrifield Office Card Number: ___________________________________ 8315 Lee Highway Fairfax, VA 22031 Expiration Date: _______________________________ USA Signature: _____________________________________ Bank ABA Number: 056001260 Account Number: Internet Society 14838710 Send via e-mail to: isoc@isoc.org File headers will be accepted as signatures. or fax to: 1 703 620 0913 or mail to: Internet Society Suite 100 1895 Preston White Drive Reston, VA 22091 USA