Individual Membership Form |

Membership Status *

New Member

Renewing Member

Date

Name *

Institutional or Business Affiliation *

Department or Division *

Position or Title *

e.g.undergraduate or graduate student

Email Address *

NOTE: Preferred method of communication is via email; announcements and notifications about upcoming events are sent via email.

Preferred Mailing Address: You can provide EITHER your home address OR your official institutional/ business mailing address. For the latter please include the name of the institution and department or division and the official mailing address (which for many institutions may be a departmental PO Box or Mail Stop Code rather than a street address).

Address *

Address

City

State/Province

Zip/Postal

Primary Phone

Phone Number *

Phone Type *

Cell

Office

Home

Secondary Phone

Secondary Phone Number

Secondary Phone Type

Cell

Office

Home

Annual Individual Membership Dues: (VAS Tax Identification Number is 54-6038285)
NOTE: Membership dues payments are based on calendar year – January 1 through December 31. Partial year memberships are not available.

Major Interest *

(select ONE)

Other Interests

(check ALL applicable)

Membership Category *

Student (undergraduate or graduate students) $20.00

Regular (all non-students including Post-Docs) $50.00

Contributing $60.00

Sustaining $75.00

Life $500.00

Patron $1000.00

Amount

Payment Method *

PayPal (you may pay by PayPal account, as guest, or credit card without a PayPal account)

Check or money order

Send this form to a third party to pay (via email)

Third Party Payor Email Address *