MEMBERSHIP APPLICATION
TO JOIN
SCIENCE AND REASON IN HAMPTON ROADS



Please print or type:


Last Name _________________________________ M _____ F _____


First Name ________________________________________________


Street ____________________________________________________


City _____________________________ State ______  Zip _________


Phone _____________________ (day) _________________________ (evening)


E-mail ___________________________________________________


 
 Membership year ends June 30.  Annual and renewal membership fees are $16.00
($8.00 for full-time students):
If joining: Regular membership fee is:
(full-time student fees are in parenthesis)
July 1 - September 30
October 1 - December 31
January 1 - March 31
April 1 - June 30 		$ 16.00   ($ 8.00)
$ 12.00   ($ 6.00)
$   8.00   ($ 4.00)
$   4.00   ($ 2.00)

 
 Membership fee paid $__________________ Date __________________


Regular membership ____________ or full-time student ______________


Occupation (or Institution, if full-time student):
___________________________________________________________


Please tell us anything you would like about your interests, skills, ideas, etc.:
___________________________________________________________

___________________________________________________________

___________________________________________________________


How did you learn of SRHR?
___________________________________________________________

___________________________________________________________

___________________________________________________________


Please print out and mail to:

Science and Reason in Hampton Roads
c/o Lawrence Weinstein
Physics Department
Old Dominion University
Norfolk, VA 23529
SRHR Website: http://www.ScienceandReason.org  or
                        http://www.physics.odu.edu/~weinstei/srhr.html