2007 Membership Application

Feel free to print this form and submit via mail or fax to:

Barbara Klewien, Administrator

c/o UPMC McKeesport

1500 Fifth Avenue, Suite 338

McKeesport, PA 15132 U.S.A.

Phone: 412-664-2943

Fax: 412-664-2569

E-mail: klewienba@upmc.edu

Please complete using typewriter or legible print

Name:

Title:

Academic degree(s):

For postdoctoral fellows: Year postdoctoral degree obtained:

For students: Year doctoral degree expected:

Institute:

First line address:

Second line address:

City: State: Country: Code:

Telephone:

Fax:

E-mail:

Dues

Member: $50.00 per year

Student/Postdoc: $20.00 per year

Enclose check made out to: The Society for Natural Immunity

Check must be drawn on a United States bank and payable in U.S. dollars

or charge to Master Card or VISA

If you elect to charge dues to Master Card or VISA, please complete the following:

Name as it appears on card:

Cardholder signature:

Billing Address:

Account number:

Expiration date:

(For security reasons, it is not recommended that you e-mail credit card information)