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 45/US$ 25; Individual -NLG 90/US$ 50; Sustaining -NLG 180/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       
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______________________

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