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NAME ____________________________________________________________
POSITION ________________________________________________________
INSTITUTION _____________________________________________________
ADDRESS _________________________________________________________
___________________________________________________________________
TELEPHONE ______________________________________________________
E-MAIL ADDRESS _________________________________________________
ANNUAL DUES * - - - - - - - - - - - - - - - - - - - - - - - - - $ 61.00
VOLUNTARY CONTRIBUTION - - - - - - - - - - - - - - ______
TOTAL- - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - ______
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CREDIT CARD # _______________________________EXPIRATION DATE _________
SIGNATURE _______________________________________________________________