Membership Application Form

Send this form to: International Hemp Association, Postbus 75007, 1070 AA Amsterdam, the Netherlands.  Please enclose the annual fee, preferably as an International Postal Money Order or an American Express or Thomas Cook Money Order.  1996 membership fees, Student: US $25 (Dfl.40) Individual: US $50 (Dfl.80) Substaining/Business: US $100 (Dfl.160) or more!

(PLEASE PRINT)

Name/organisation

Street address

City

State/Province

Postal Code

Country

Tel

Fax

e-mail

Membership:          O Student          O Individual          O Sustaining/Business

Main field of interest or expertise

Can we include your name, address and field of interest or expertise in a membership list to be made available to our members?    O Yes    O No

AmEx Info:

Date

Amount

Exp. Date

Charge to my AmEx card no.

Signature