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Membership Application Form

Send this form to: International Hemp Association, Postbus 75007, 1070AA Amsterdam, the Netherlands.Please enclose the annual fee, preferably as an International Postal Money Order or an American Express or Thomas Cook Money Order.US$ personal checks accepted. 1999 membership fees, Student: US $25 (NLG l.50) Individual: US$50 (NLG 100) Sustaining/Business/Library: US $100 (NLG 200) or more! (PLEASEPRINT)

Name/organisation ___________________________________________________

Street address _______________________________________________________

City ___________________________ State/Province ______________________

Postal Code _____________________ Country ___________________________

Tel ____________________ Fax ___________________ e-mail _____________

Membership: 0 Student 0 Individual 0 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? ( ) Yes ( ) No

Please charge my American Express, Visa, MasterCard (circle one)

Info: Date ___________ Amount _____________ Exp.Date ______________

Charge to my card no. __________________ Signature___________________