The Gesneriad Society Membership Application

Use this form to make application by mail only.

Please make checks or money orders payable, in US$ on a US bank to The Gesneriad Society, Inc. If you are paying by credit card (Visa or MasterCard only), include your card number, expiration date and signature.

Complete the application form below, print and mail with payment to:

Bob Clark
Membership Secretary
1122 East Pike Street, PMB 637
Seattle, WA 98122-3916

* required information

Membership

	New Member
	Renewal	Membership Number:

Membership Rates are US$

Membership Level	US Mailing 1 Year		US Mailing 3 Years		Mailing Outside US 1 Year		Mailing Outside US 3 Years
Individual		$25		$70		$30		$85
Family		$26		$73		$31		$88
Sustaining		$35		$105		$40		$120
Research		$50		$150		$55		$165
Life		Mailing in US: $375.00				Mailing outside US: $450.00
Gesneriads is mailed first-class to members outside the US and bulk-rate within the US

Your Information

First Name:*

Last Name:*

Email:*

Address 1:*

Address 2:

City:*

State:*

Province:

Country:

Zip/Postal Code:*

Phone*:

How did you hear about us:

Credit Card Information

Card Holder Name:*

Credit Card Number:*

Credit Card Type:

Credit Card Expiration:

Billing Information

Please check this box if your credit card information is the same as your contact information.
If not, please fill out the information below: