Membership Form
New Mexico Academy of Science
New Membership [
]
Renewal [ ] (Calendar Year______)
Date: _________________
Name: ____________________________
Title: ______________________________
Employer/Firm (or other):
___________________________________
___________________________________
___________________________________
Specialities/Interests
___________________________________
___________________________________
Mailing Address:
___________________________________
___________________________________
___________________________________
Work Phone:_______________
Home Phone:_______________
FAX: _______________
e-mail:_______________
Check if address different from past record [ ]
Membership Class (check one):
[ ]Member $25/year
[ ]Student $15/year, School____________
[ ]Subscription $25/year (Libraries only)
[ ]Life Membership $400 (3/4 of Life Membership goes to NMAS Endowment)
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[ ]Tax Deductible Gift to NMAS Endowment $_______________
[ ]Tax Deductible Gift $_______________
Total:$____________________________
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Send check payable to "NMAS" to:
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New Mexico Academy of Science
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c/o New Mexico Museum of Natural History
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1801 Mountain Road NW
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Albuquerque, NM 87104
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to NMAS Home Page
Last Updated, DPD, 11/14/2010