Internet Society
Individual Membership Application 

Please enroll me as an individual member of the Internet 
Society. In addition to being a significant contribution to 
the evolution of the Internet and its use, membership 
entitles me to a subscription to OnTheInternet magazine, 
a subscription to the ISOC Forum (the Internet Society's
organizational and informational electronic newsletter),
reduced rates at Internet Society conferences, 
and other benefits.

__  Individual Membership _ $35 Annually

__  Student Membership _ $25 Annually

Name
Title
Organization/Institution
Postal Address

E-mail Address
Telephone
Fax

Please check the box that best describes your position:
__  Owner/President/CEO/CIO
__  Director/Manager
__  Product Development Manager
__  Systems Manager/Administrator
__  Network Manager/Administrator
__  Marketing/Advertising Manager
__  Engineer
__  Programmer
__  Professor/Associate Professor
__  Researcher/Assistant
__  Librarian
__  Consultant/Self-Employed
__  Student
__  Other

Please check the box that best describes your organization:
__  Network Service 
__  Software Company
__  Information Systems Management
__  Product Provider
__  Educational Institution
__  Nonprofit Organization
__  Public or Private Library
__  Publisher
__  Other

Payment may be made by check, credit card, money order, or
wire transfer. U.S. currency only.

__  Payment is enclosed.

Please bill my 
__  American Express
__  MasterCard
__  Visa

Card No.
Expiration Date
Cardholder's Name 
Signature

Send wire transfers to:

Internet Society Acct. No.148 38 710
ABA No. 054000030
Riggs National Bank of Virginia
950 Herndon Parkway
Herndon, VA  20171
U.S.A.

Send checks and money orders to:

Internet Society
12020 Sunrise Valley 
Drive, Suite 210
Reston, VA 20191-3429
U.S.A.