BSA Membership Application

P.O. Box 1537, Lenox Hill Station, New York, NY 10021
P H O N E / F A X : (212) 452-2710 E - M A I L : bsa@bibsocamer.org
W E B : www.bibsocamer.org

M E M B E R S H I P A P P L I C A T I O N F O R M

Mr. / Ms. / Mrs. / Miss / Dr. / Prof. (please circle one)

Name:

H O M E A D D R E SS :

Address:

City:

State:

Postal Code:

Country:

Telephone:

Fax:

E-mail:

B U S I N E S S A D D R E S S :

Company:
Address:

City:

State:

Postal Code:

Country:

Telephone:

Fax:

E-mail:

Please send mail to:

Home

Business

Publish this address in the annual directory of members:

Home

Business

Do NOT list my telephone number, fax number, or e-mail address in the annual list of BSA members.

Membership Category (please check one):

Life

$1,250

Annual Individual

$65 US / $80 Non-US

Sustaining*

$250 US / $265 Non-US

Student**

$20 US / $35 Non-US

Contributing*

$100 US / $115 Non-US

Institutional

$100 US / $115 Non-US

Other Contribution***

All Non-US memberships include a $15 surcharge for postage

* All but $50.00 of Contributing and Sustaining memberships are tax deductible.
** Student members must enclose a photocopy of current, valid school I.D. or transcript.
*** The Bibliographical Society of America is a 501(c)(3) charitable organization. All contributions to the Society are tax deductible to the extent provided by law.

Please make check/money order payable to BSA and remit with application form to address at top of page. All checks/money orders must be in U.S. currency and drawn on a U.S. bank. Please do not send cash. Or you may pay by credit card.

Credit Card Type: VISA MasterCard	(We accept VISA and MasterCard only)

Name on Credit Card:

Number:

Exp. Date:

Signature: