Internet Society
Organizational Membership Application

Please establish my organization as a member of the Internet
Society. In addition to being a significant contribution to
the evolution of the Internet and its use, membership 
entitles my organization to representation on the Internet
Society's Advisory Council, a subscription to OnTheInternet
magazine, reduced rates for society conferences, and other
benefits of special interest to organizational members.

__  Sustaining Gold Membershio
    For-Profit Organization, $50,000 Annually

__  Sustaining Gold Membershio
    Nonprofit Organization, $25,000 Annually

__  Executive Membership
    For-Profit Organization, $10,000 Annually

__  Executive Membership
    Nonprofit Organization, $5,000 Annually

__  Principal Membership
    For-Profit Organization, $5,000 Annually

__  Principal Membership
    Nonprofit Organization, $2,500 Annually

__  Professional Membership
    For-Profit Organization, $2,500 Annually

__  Professional Membership
    Nonprofit Organization, $1,250 Annually

__  Start-Up Membership
    For-Profit or Nonprofit Organization During the 
    First Three Years of Operation--$1,000 Annually


Contact Person
Organization/Institution
Postal Address
 
E-mail Address
Telephone
Fax

Billing Address (if different from above)


As the contact person, please check the box that best
describes your position:

__  Owner/President/CEO/CIO
__  Director/Manager
__  Product Development Manager
__  Systems Manager/Administrator
__  Network Manager/Administrator
__  Marketing/Advertising Manager
__  Engineer
__  Programmer
__  Professor/Associate Professor
__  Researcher/Assistant
__  Librarian
__  Consultant/Self-Employed
__  Student
__  Other

Please check the box that best describes your organization:

__  Network Service 
__  Software Company
__  Information/Systems Management 
__  Product Provider
__  Educational Institution
__  Nonprofit Organization
__  Public or Private Library
__  Publisher
__  Other


Payment may be made by check, credit card,  money order, or wire transfer.
U.S. currency only.

__  Payment is enclosed.
__  Please bill my organization.

Credit Card information:

   __  American Express
   __  Mastercard
   __  Visa

   Credit Card Number:  __________________________________
   Name on card:        __________________________________
   Expiration Date:     ___________

Send wire transfers to:

Internet Society Acct. No.148 38 710
ABA No. 054000030
Riggs National Bank of Virginia
950 Herndon Parkway
Herndon, VA  20171

Send checks and money orders to:

Internet Society
12020 Sunrise Valley Drive, Suite 210
Reston, VA 20191-3429
U.S.A.

Phone: 800-468-9507 (U.S.A. only) or +1 703-648-9888
Fax: +1 703-648-9887
org-membership@isoc.org * http://www.isoc.org