IASA Membership Application Form

Membership Application Form
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SUBMISSION INSTRUCTIONS:
(It is important that you complete both steps below.)

1. Please print this form, fill it out, and mail or fax to:

Prof. Theo D'Haen
Executive Director, IASA
English Dept.
Leiden University
P.O.Box 9515
NL-2300 RA Leiden
THE NETHERLANDS
FAX: +31 71 5272149

2. For our membership files, please send an e-mail containing the following information to iasa@psu.edu:

First and Last Names
Title/Appointment
Affiliation/Institution
Street Address
City
State
Zip/Postal Code
Country
Phone
E-mail address
Gender

Highest degree obtained
Year degree obtained
Field in which degree obtained
Institution from degree granted
Current employment (indicate academic, student, emeritus, nonacademic, or unemployed)
Area(s) of Specialization

Please print this form and provide the following information:

First and Last Names	________________________________________________
Title/Appointment	________________________________________________
Affiliation/Institution	________________________________________________
Street Address	________________________________________________
City	________________________________________________
State	________________________________________________
Zip/Postal Code	________________________________________________
Country	________________________________________________
Telephone	________________________________________________
E-mail address	________________________________________________
Gender (circle one)	Male or Female
Highest degree obtained	________________________________________________
Year degree obtained	________________________________________________
Field in which degree obtained	________________________________________________
Institution from degree granted	________________________________________________
Current employment (circle one)	academic, student, emeritus, nonacademic, or unemployed
Area(s) of Specialization	________________________________________________

IASA Membership Annual Dues Schedule:
(Please indicate your membership level)

	under $10,000 annual income	$5 annual dues
	$10,000-$20,000 annual income	$10 annual dues
	$20,000-$30,000 annual income	$20 annual dues
	$30,000-$40,000 annual income	$30 annual dues
	$40,000-$50,000 annual income	$40 annual dues
	$50,000-$60,000 annual income	$50 annual dues
	$60,000-$70,000 annual income	$60 annual dues
	$70,000-$80,000 annual income	$70 annual dues
	$80,000-$90,000 annual income	$80 annual dues
	over $90,000 annual income	$100 annual dues
	Lifetime membership	$1,500
	Institutional membership: $250 maximum (figured as $10 per $1000 annual budget, with a ceiling of $250)
	National/regional association: Partnership (secured at ONE Institutional membership rate)

Method of Payment:
(Payment may be made in USDollars or in Euro at current exchange value. Select one of the two options below.)

Option A: Electronic Transfer

Electronic transfer TO:	Bank swift code: ABNANL2A
Account number:	489074219
To the name of:	International American Studies Association - IASA

Option B: Visa Card (MasterCard dues payment only possible with Congress Registration form)

Your Visa Card # + last 3 digits (safety code) from signature strip on back of your card:
	__________________________________________________________________
Expiration Month:	__________________________________________________________________
Expiration Year:	__________________________________________________________________
Name on Card:	__________________________________________________________________
Signature:	__________________________________________________________________
Payment Amount:	$_________________________________________________________________