AWM Institutional Membership Form

AWM Institutional Membership Form
2005/2006

Part I: Directory & Mailing Information

Institution	:	________________________________________________
Dept.'s Email	:	________________________________________________
Dept.'s URL	:	________________________________________________
Chairperson	:	________________________________________________
Dept.'s Address	:	________________________________________________
		________________________________________________
		________________________________________________
Dept.'s Phone	:	________________________________________________
Chair's Phone	:	________________________________________________
Dept.'s Fax	:	________________________________________________

Part II: Dues Schedule

Please check the appropriate membership category below. Make checks or money orders payable to: Association for Women in Mathematics. NOTE: All checks must be drawn on U.S. Banks and be in U.S. Funds. AWM Membership year is October 1st to September 30th.

o	Category 1 (10 students memberships, 1 free ad, 25% discount*)	$300	$__________
o	Category 2a (3 students memberships, 1 free ad, 10% discount*)	$175	$__________
o	Category 2b (6 students memberships, no free ad, 10% discount*)	$150	$__________
	TOTAL ENCLOSED		$__________

* Benefits of membership are described on the AWM Academic Institution Membership page.

Please indicate the number of student nominees included on this form: ________
List names, addresses, and emails of student nominees on opposite side or attach separate page.

Return form, nomination list, 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@awm-math.org.