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Membership Application Form
Please print this page and fill out the membership form below.Please complete the following information:
| Name: | ___________________________________ |
| Street Address: | ___________________________________ |
| City, State: | ___________________________________ | Zip: | ___________________________________ |
| Country: | ___________________________________ |
| Telephone: | ___________________________________ |
| Fax: | ___________________________________ |
| 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 |
| ___ FOUNDING (must be at least 18 years of age) | $50 annual dues, plus $125 one time only |
| ___ 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 |
| Non Voting Members: | |
| ___ ASSOCIATE (under 18 years of age only) | $25 annual dues |
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 national conference.
Method of payment:American Synesthesia Association, Inc.
75 East 4th Street Ste. 573
New York, New York 10003
Please make your check or money order payable to the American Synesthesia Association, Inc.