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APUA Membership Form
All members receive the quarterly APUA Newsletter. Thanks for your support!
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Name: |
Title: |
Address: |
Organization: |
City, State: |
Telephone: |
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Fax: |
Zip Code: |
Email: |
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| Individual Membership |
Supporting Membership* |
Corporate Membership |
| ___ Student ($20) |
___ 1-Year Supporting ($55) |
___ Affiliate ($1,000) |
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___ 1-Year Individual ($45) |
___ 2-Year Individual ($95) |
___ Associate ($2,500) |
| ___ 2-Year Individual ($70) |
___ Friend ($250) |
___ Partner ($5,000) |
| ___ Institution/Library ($100) |
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___ Benefactor ($10,000) |
| *supports member in a developing country |
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Payment amount: $ _____________
If payment is not in US dollars, please specify currency. Memberships are tax deductible in the US. |
___ Check drawn from a US affiliated bank made payable to APUA
___ International money order made payable to APUA
___ MasterCard
___ Visa
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Card Number:
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Expiration:
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Signature:
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Today's Date:
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Mail or fax this completed form to:
APUA Membership, 75 Kneeland Street, Boston, MA 02111-1901, USA
Fax: 617-636-3999
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www.apua.org |
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ALLIANCE FOR THE PRUDENT
USE OF ANTIBIOTICS © 1999
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