Feedback/Membership Form

Please identify and describe yourself:

Name
Date of Birth	(for individual)
Sex	Male Female

Please provide the following contact information:

Name
Title
Organization
Street Address
Address (cont.)
City
State/Province
Zip/Postal Code
Country
Work Phone
Home Phone
FAX
E-mail
URL

Choose one of the following options:

Contribution Type Any Amount of your choice Ordinary Membership: Rs. 100/(US$10)/year Student Pool Fund: Rs. 300 (US$20)/year Scholarship: Rs. 600/(US$50)Student/year Life Membership: Rs.5000/(US$300) Corporate Membership: Rs. 10,000/(US$500)