AWM Individual Membership Form

AWM Individual Membership Form: 2004/2005

Part I: Directory & Mailing Information

Name (Last, First, MI)	:	________________________________________________
Address	:	________________________________________________
		________________________________________________
		________________________________________________
Email	:	________________________________________________
Home Phone	:	________________________ do not publish home number
Work Phone	:	________________________ do not publish work number

I do not wish for my AWM membership information to be released to the Combined Membership List.

Part II: Professional Information

Position	:	________________________________________________	If student, GRADUATE or UNDERGRADUATE? (circle one)
Institution/Company	:	________________________________________________
City, State, Zip	:	________________________________________________

Part III: Degrees Earned

		Field(s)	Institution(s)	Year(s)
Doctorate	:
Master's	:
Bachelor's	:
Primary Fields of Interest (click here for list of codes) : _____ _____ _____ _____ _____

Part IV: Dues Schedule

Regular Individual Membership For NEW Individual members: Join at the reduced rate of $30 for the 2004/2005 membership year [ valid through 30 June 2005 ]	$50	$__________
2nd Family Membership (no Newsetter) Please indicate regular family member: ______________________________	$30	$__________
Contributing Membership	$100	$__________
Retired or Part-Time Employed Membership (circle one)	$25	$__________
Student, Unemployed, or Developing Nation Membership (circle one)	$15	$__________
Additional Postage for All Foreign Memberships (Including Canada & Mexico)	$ 8	$__________
I am also enclosing a donation to the "AWM General Fund"		$__________
I am also enclosing a donation to the "AWM Alice T. Schafer Prize Fund"		$__________
I am also enclosing a donation to the "AWM Anniversary Endowment Fund"		$__________
TOTAL ENCLOSED		$__________

I wish for my contribution/donation to remain anonymous.
This is a gift from _______________________________________________ We will send the recipient a notice that the gift membership is from you.

Dues in excess of $15 and all donations are deductible from U.S. federal income taxes.

Make checks or money order payable to: Association for Women in Mathematics. All checks must be drawn on U.S. Banks and be in U.S. Funds. AWM Membership year is October 1st to September 30th. Dues in excess of $15 and all contributions/donations are deductible from federal taxable income.

Return form and dues to: Association for Women in Mathematics Membership
11240 Waples Mill Road
Suite 200
Fairfax, Virginia 22030

Questions? Call 703-934-0163 or email: awm@math.umd.edu.