Individual Membership Application Form

Name:_________________________________________________________________

Affiliation/Organization:________________________________________________

Address:______________________________________________________________

_______________________________________________________________

City:_________________________________________________________________

State:_________________ Zip Code:______________________________________

Phone:________________________________________________________________

Fax:__________________________________________________________________

Electronic Mail Address:________________________________________________

Check the membership applicable to you below:

• Student, SEDS chapter member (Chapter Name:__________________) Dues: $10/year

• Student, non-chapter member (School Name:__________________) Dues: $20/year

• Non-student Dues: $25/year

• Additional Donation ($____________)

Submit payment (make checks payable to SEDS-USA) with this form to:

SEDS-USA

c/o MIT SEDS

Room W20-445

77 Massachusetts Ave.

Cambridge, MA 02139

Phone: (617) 253-8897 (push * button to fax)

Email: jeff@astron.mit.edu