IPMS No. ________ Name __________________________________________
     (Leave Blank if New)     First       MI                  Last

     Address: _______________________________________________________

     ________________________________________________________________

     City:_____________________________ State: _____ Zip: ________-______

     Email: _____________________________________________________________
     
     Phone: Area Code:_______Number:____________________________
     
     Chapter Affiliation, if any: _______________________________________

     ( Current Members Only )
     __ Check here if new address, and list old Zip Code _______-_____

    __ Junior (17 years old and younger) $9; Birthdate: ____________
    __ Adult $21;    __ Adult 2 Yrs $41;    __ Adult 3 yrs $61
    __ Canada & Mexico $25; __ Foreign(Sea) $28; __ Foreign(Air) $45
    __ Family (Adult Membership + $5, one set of Journals, 
	     number of Membership Cards required ____)

	__ If recommended by an IPMS member, please provide his/her

     Name: ______________________________ IPMS# ___________

	Payment Options: Credit Card_____Check______Money Order_____ _Paypal_______  

	 (PayPal payments in U.S. Dollars only, please)

	If by VISA/MasterCard Credit Card, please provide the following information: 
	
	Type card (MC or Visa)______ Account No _______________________________ 
	
	Expiration date _____________
	
	Credit Card Billing Address;
	
	_______________________________________________________________

	________________________________________________________________

	City:_____________________________ State: _____ Zip: ________-______	
	NOTE - Card Billing Address must include Zip code:
	
	Mail completed application to IPMS/USA addess below 
====================================================================================================
	If by Check/Money Order, Mail completed application and  Check/MO payable to IPMS/USA to:
       
          IPMS/USA
          Dept. H
          PO Box 2475
          N. Canton, OH
          44720-0475
          
      OR:
      
      If using PayPal** to make payment; 
      
	1. Set up a, or use your existing, PayPal Account; and 
	 a. Authorize Payment and Amount payable to ipms@emkinney.com
	    for "IPMS/USA Membership". U.S. Dollars only, please.
	 
	2. E-Mail completed IPMS/USA Application above to; IPMS/USA

	**PayPal is a widely used, well established, and reliable
	 worldwide payment service used to transfer payments over the Internet
 	 using your Credit Card or Checking Account. With your PayPal account 
 	 you can pay anyone with an email address -- even if they don't have 
 	 a PayPal account. 

	 For complete information on PayPal, to Sign Up for your FREE
	 Personal Account, or to make Payment - go to PayPal 	

RRF March 13, 2002