Become a Member of the Association

Become a member:
***This is a secured form***

A regular membership is $40 per calendar year. Subscription to the Dr. Clark Research Association Bulletin is included in the membership fee. Sponsor status is $100 per calendar year. There are no extra benefits, this is just a way of making an extra contribution to the cause. We try to give the sponsors preferred treatment. Any other amount is welcome.

First Name: Last Name:
Address:
City/State: ZIP Code:
Country:
Phone #:
E-mail address:
Credit Card number: exp. date:
VISA, Master Card, Euro Card, American Express.
.
I would like to be a regular member ($40/year)

I would like to be a sponsor ($100/year)

I would like to make the following contribution:

I'd rather pay by personal check (US only)
[Send your check and order to:
Dr. Clark Research Association
643 South Main St.
Georgetown, IL. 61846]

info@drclark.net
Last Changes: 16 March 2004
(c)1999-2004 Dr. Clark Research Association and David P. Amrein
home

First Name:		Last Name:
Address:
City/State:		ZIP Code:
Country:
Phone #:
E-mail address:
Credit Card number:		exp. date:
VISA, Master Card, Euro Card, American Express.
.
	I would like to be a regular member ($40/year)
	I would like to be a sponsor ($100/year)
	I would like to make the following contribution:
	I'd rather pay by personal check (US only) [Send your check and order to: Dr. Clark Research Association 643 South Main St. Georgetown, IL. 61846]