Membership Application Form
Full Name (Print) Dr., Prof., Mr.,
Mrs., Miss
____________________________________
Profession ___________________________________
Title ______________________________
Organization/University _________________________________________
Mailing address _____________________________________
City _____________________ State ____________________
Zip ________________ Country ________________________
Complete this form and fax or mail it with your check-or-credit card (Do
not
Total amount enclosed or to be charged U$S ___________ Euros $__________
[ ] Check or money order, payable to ATHENAEUM in U.S funds or Euros
funds, enclosed.
[ ] VISA [ ]
MasterCard [ ]
Other
Credit Card #_________________________
Exp. date ___________________
Cardholder's Name (print) ___________________________________________
Phone ( ) ___________________________________________________
Authorized Signature ____________________________ Date _______________