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Dues Application Form
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Page #2
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| Must
be completed by ALL Members |
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Please TYPE or PRINT) Complete
ALL Information and Return with your Dues Payment.
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| All
completed Forms Must Accompany Payment for Processing by ICP. |
Check if new address: ________
| Title:
_______ Full Name:
__________________________________________________________________________
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First |
Middle Initial |
Last |
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| Email Address:
_______________________________________________________________ |
| Please TYPE or PRINT in CAPITAL
LETTERS
(Please include your email address. Email is the prime means of
communicating with ICP members and it decreases costs for both ICP
and you.) |
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| Home Address:
_________________________________________________ City
____________________________ |
| State _______________________________
Zip/Postal Code: __________________ Country: _______________ |
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| Home telephone:
____________________________________ Fax: -_______________________ |
| Office telephone:
____________________________________ Fax: _______________________ |
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| Please return your payment with ALL
COMPLETED FORMS. |
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| Enclosed is my check for $
___________________ (U.S. Dollars) |
PAYMENT OPTIONS:
_____ Pay by check only (US$ only) OR ____ Credit
Card (Only VISA /MASTERCARD accepted)
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1. POSTAL MAIL ____________
Send your Membership Form & Payment Form with your *Check made to
ICP: |
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| Mrs. Paula R. Leder, ICP Financial
Officer |
| c/o Dr. Matti K. Gershenfeld,
Secretary General |
| The
Colonade, Suite #1201 |
| 100 Old York Road |
| Jenkintown, PA 19046 |
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Enclosed is my check for $
___________ (U.S. Dollars only) |
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______ Enclosed are my completed 2004 Membership/Dues Forms |
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Note:
Sorry, but we cannot accept Wire Transfers. |
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*All Checks must be
made from a USA Bank, & must include a contact name and telephone
number on the check.) |
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2. FAX or Email -
You may fax or Email your
completed dues statement only if paying by credit card)
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Email:
pleder@nni.com
Fax: 215-884-4665 |
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| 3. Credit
Card Authorization Form (TYPE or PRINT clearly) |
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Complete and return both the Dues & Membership forms
and the Credit Card Authorization for processing. |
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| I authorize
______VISA or ______Mastercard payment for $ ____________ (U.S. Dollars
to ICP) |
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Card Number ________/__________/____________/___________/ Expiration
date ______________ |
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Requires
16 Digits
MM / YYYY |
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NOTE: PRINT FULL NAME & ADDRESS EXACTLY as it appears
on your Billing Statement from V or MC - INCLUDING FULL
ZIP/MAIL CODE. If incorrect, we / you will be assessed
a “Charge Back” Fee from V or MC in the amount of $20 US$ .
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Full Name:
_____________________________________________________________________
Complete Address:
___________________________________________________________________
City:
_______________________________
State: _____________ Zip/Postal Code _________ Country_____________ |
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Signature _________________________________________
Date: ____________________ mm/yyyy
Telephone___________________________
EMAIL____________________________________________
Type or Print in Capital Letters |
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