Foresight Institute
Membership Application

To instead use a secure server for
application on line with a credit card 		PLEASE PRINT
and fax or mail this form to:
Foresight Institute, Box 61058
Palo Alto CA 94306 USA
Tel: 415-917-1122 Fax: 415-917-1123
Yes, I want to join the nanotechnology effort by becoming a Senior Associate. Send me the Senior Associate Letters and invite me to the annual gathering. My pledge is at the following level:
Associate$250 annually for five years.
Fellow$500 annually for five years. Includes signed gift book.
Colleague$1000 annually for five years. Includes framed signed artwork.
Friend$5000 annually for five years. Includes engraved crystal "Friend of Foresight" award on ebonite base and the signed framed artwork.
This gift
is an:		Individual contributionCorporate contribution
A matching gift will be made by my company
Name: _______________________________________________

Address: ______________________________________________

City, State: ____________________________________________

Zip Code/Postal Code, Country: ___________________________

Phone: __________________________ Fax: __________________________

Email: _______________________________________________

My first annual donation is enclosed, payable to the Foresight Institute. Foresight is a nonprofit foundation; donations are tax-deductible in the U.S. to the full extent permitted by law. Donations can be made by check from a U.S. bank, postal money order, VISA, or Mastercard. Credit card donations may be sent by fax.

VISA or Mastercard Number:_______________________

Exp. Date:_________ (Month/Year) Signature ________________________________
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The URL of this document is: http://www.foresight.org/SrAssoc/Application.html