Please fill out the following:

First Name:	___________________________________
Last Name:	___________________________________
Street Address:	___________________________________
City, State, Zip:	___________________________________
Telephone Number:	___________________________________
Fax Number:	___________________________________
E-mail Address:	___________________________________
Website:	___________________________________

Please select from one of the following categories of ASA membership:

Voting Members:
___ GENERAL (must be at least 18 years of age)	$50 annual dues
___ SUSTAINING (must be at least 18 years of age)	$500 annual dues
___ PATRON (must be at least 18 years of age)	$1,000 annual dues
___ LIFETIME (must be at least 18 years of age)	$5,000 one time only

The ASA is a not-for-profit, tax exempt organization whose educational mission encourages people to learn more about synesthesia. It is membership supported, so by becoming a member you will actively support this work. We encourage you to join the ASA, and we hope you can attend our upcoming international conference.

Method of payment:

Membership is ONLY for individuals over 18 years of age:

Via Credit Card:

Annual Membership

General $50.00 USD Sustaining $500.00 USD Patron $1,000.00 USD Lifetime (one-time) $5,000.00 USD

Member Name

Member Email

Note: You do not need to pay via a Paypal account; simply click Pay with Debit or Credit Card.

Via Check or Money Order:

Please print out a copy of this membership, fill it out, and send it with your check or money order via regular mail to:

American Synesthesia Association, Inc.
90 Morningside Drive, 3B
New York, NY 10027


Please make your check or money order payable to the American Synesthesia Association, Inc.