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Membership Application Form
Send this form to:  International Hemp Association, Postbus 75007, 1070 AA Amsterdam, the Netherlands.  Please enclose the annual dues, preferably as an International Postal Money Order, American Express credit card authorization or Eurocheque.  For 1995, annual membership fees are:  Student - NLG 40/US$ 25;   Individual - NLG 80/US$ 50;  Sustaining - NLG 160/US$ 100 or more (PLEASE PRINT BLOCK LETTERS)

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

Date _________________ Signature

O Charge my American Express card #__________________________________________
                            Expiration date______________________