Application for Membership



To:      Internet Society

         Please enroll me as a member of the Internet Society.  I
         understand that membership entitles me to receive the
         quarterly Internet Society News, reduced fees for attendance
         at Internet Society conferences and other benefits. 
         Membership privileges will be for twelve months from the
         receipt of payment.  I am applying for

             ____ regular membership at $70.00

             ____ student membership at $25.00 (please send proof
                  of status)

Name:_____________________________________________________________

Postal Address:  _________________________________________________

                 _________________________________________________

                 _________________________________________________

                 _________________________________________________

Internet Address:_________________________________________________


             ____ Please bill me.

             ____ Payment is included with this application as below.


Payment Information:  Payment of Internet Society annual dues may be 
		      made via check, money order, credit card or wire 
		      transfer.  

For credit card payments:                            Send wire transfers to:

__AMEX __VISA __MC __DINERS __CARTE BLANCHE          Bank:  Riggs Bank of 
							      Virginia
                                                            Merrifield Office
Card Number: ___________________________________	    8315 Lee Highway
            						    Fairfax, VA  22031
Expiration Date: _______________________________	    USA

Signature: _____________________________________    Bank ABA Number: 056001260
                                                    
						    Account Number:  Internet
								     Society
                                                                     14838710

           Send via e-mail to:  isoc@isoc.org
                                File headers will be accepted as signatures.
     
           or fax to:           1 703 620 0913

           or mail to:          Internet Society
                                Suite 100
                                1895 Preston White Drive
                                Reston, VA  22091  USA