IAGLR 2012 Membership Application

Contact Information

Type of Membership (Circle)

Name

	Electronic	Elect. & Print
Individual
Regular	$130	$165
Student	$35	$70
Young Professional	$65	$100
Retiree	$65	$100
Life	n/a	$2475 (one-time fee)
Corporate/Institutional
Sustaining	$1500	$1650
Developing Countries
Regular	$5	n/a
Student	$3	n/a

Business Address

Mailing Address (if different)

Work Phone

I would like to... (Circle)

Home Phone

Be listed in members-only directory (See Privacy Policy): Yes No

Fax

Volunteer for IAGLR: Yes No

E-mail

Subscribe to IAGLR's biweekly email newsletter: Yes No

Background Information

Form of Payment

Highest Academic Degree

Check	Check #:
Money Order	Money Order #:
Credit Card: (MasterCard or Visa only)	Card #:
	Card Security Code: (typically 3-digit code on back of card)
	Exp. Date
	Authorized Signature

Degree Specialty

Year

Institution

Current Area of Research

Professional Title

Date

Contribution to IAGLR *
I'd like my contribution to support the following:	Amount
Paul W. Rodgers Scholarship Fund	$_____________
IAGLR Conference Student Travel Awards	$_____________
IAGLR Endowment Fund	$_____________
IAGLR Scholarship Fund	$_____________
No preference, general contribution	$_____________
TOTAL AMOUNT DUE (Dues + Contribution)	$_____________

Please return your check (payable to IAGLR) to Treasurer, IAGLR Business Office, 4840 South State Road, Ann Arbor, Michigan, USA 48108. You also may fax this form with credit card information to IAGLR at (734) 741-2055. All payments must be made in U.S. equivalent currency. Please allow 5-10 business days for processing.

* IAGLR is a U.S. non-profit 501(c)(3) organization. Donations are deductible from U.S. income tax and deductible against U.S. earnings in Canada. IAGLR is also a Canadian non-profit organization with charitable status pending.