Membership Application Form

Membership Application Form

Send this form to: International Hemp Association, Postbus 75007, 1070 AA 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. 1996 membership fees, Student: US $25 (Dfl.50) Individual: US $50 (Dfl.100) Substaining/Business: US $100 (Dfl.200) or more! (PLEASE PRINT)

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 member-ship

list to be made available to our members?     0 Yes     0 No

AmEx Info: Date _________ Amount ____________ Exp. Date _____________

Charge to my AmEx card no. ________________ Signature _________________