APPLICATION FOR MEMBERSHIP:  THE LEPIDOPTERISTS' SOCIETY    

NAME (please print or type):
TITLE (optional; e.g., Ph.D.; M.D.; Ms.):
ADDRESS:

CITY:
STATE:
ZIP/POSTAL CODE:
COUNTRY:
HOME TELEPHONE, with Area Code (optional):
WORK TELEPHONE, with Area Code (optional):
FAX NUMBER, with Area Code (optional):
e-mail:
URL:

Please check the class of membership desired:
[   ] Active (Regular): $45.00
[   ] Affiliate (enter full names here): $10.00 each
[   ] Student (certify below): $20.00
[   ] Sustaining: $60.00
[   ] Life Membership (one time): $1,800.00
[   ] Institutional Subscription: $60.00

[   ] FOREIGN POSTAGE:all members outside U.S.A., ADD $5.00

[   ] (optional) Air Mail postage for the NEWS (first class in U.S.A.):
          [   ] $15.00 to members in U.S.A., Canada, and Mexico
          [   ] $30.00 to members in all other countries

Total Amount Enclosed ...............................$_________

Payment Method (cash and endorsed traveler's checks are accepted *at sender's risk only!*):
[   ] check [   ] money order [   ] Visa or [   ] MasterCard

Complete Charge Card Number:

Expiration Date:

Signature of Cardholder:

Dues must be paid in U.S. Dollars (personal or bank check drawn on a U.S. bank; money order; international postal money order), payable to "The Lepidopterists' Society," OR charged to Visa or MasterCard. All payments and charge orders (with original signature) must be mailed to the Treasurer. We regret that we do not yet accept credit card payments by telephone or the Internet.

New members or those returning to membership after at least 5 years absence: check one of these options.

_____   Get ALL of the 2006 publications, pay dues again in 2007.    
_____   SPECIAL OFFER: get the rest of 2006 publications from time of payment receipt and ALL of 2007 publications.

Print the completed application and mail with your payment or charge card authorization to:

The Lepidopterists' Society
Kelly M. Richers, Treasurer
9417 Carvalho Court
Bakersfield, CA 93311-1846, U.S.A.

[The information you supply below is optional; you may choose to have some or all of it omitted from the Membership Directory.]

My Lepidoptera interests are (check all that apply; supply separate information for each affiliate member, if desired):

[   ] Rhopalocera (butterflies)
[   ] Macro-heterocera (larger moths)
[   ] Micro-heterocera (smaller moths)
[   ] All Lepidoptera (e.g., all of the above)
[   ] Butterfly Gardening
[   ] Butterfly Watching
[   ] Photography
[   ] Life Histories
[   ] Rearing
[   ] Parasites
Other (include families/genera of special interest, geographic areas of interest, etc.):

I also: [   ] Collect; [   ] Exchange; [   ] Buy; [   ] Sell specimens.

PRIVACY NOTICE (due to the nature of the membership database, these are the only options available, and you may choose only one, if any):
Please OMIT the following from the Membership Directory:
[   ] telephone numbers [e-mail and Fax numbers will be published]
[   ] address AND telephone numbers [name only will be published]
[   ] entire listing [you will not be in the Membership Directory and your name will not be rented to approved renters of the mailing list]

STUDENT CERTIFICATION. If you are applying for Student Membership, please provide the following information and signatures:

Name of educational institution you are attending:

City, State, Country of educational institution:

Signature of Applicant:

Student Identification Number:

Signature of professor, teacher, or parent: