MEMBERSHIP APPLICATION - Calendar Year 2012

Use this for to pay by CHECK

Your Name:
Address for FAS mailings:
City:
State:
Zip:
Home Phone:
E-Mail:
University Affiliation or Employer:
University or Employer Address:
City:
State:
Zip:
Phone:


MEMBERSHIP LEVELS

Regular $35.00

Student $20.00

Sustaining $45.00

Life $500.00 		Patron $1000.00

Corporate $200.00

Institutional $100.00

CONTRIBUTIONS

FLORIDA ENDOWMENT for Sciences (a Trust Fund for FAS awards, special projects). $
Dr. Elizabeth A. Hays Travel Award Fund $
Academy Operating Funds $
Please select a FAS section of interest from the list:  

Payment Total Amount

 

Print and Mail completed form to:
Florida Academy of Sciences
Orlando Science Center
777 East Princeton Street
Orlando, FL 32803
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