Print out and complete the application.  Send payment and application to:
Florida Entomological Society, P.O. Box 1007, Lutz, FL 33548-1007
(PH: 813-903-9234, FAX: 813-979-4908) email: flaentsoc@att.net)

Please enroll me as a: ___ New Member     ___ Renewing Member   for the year beginning January 1, _____

______________________
First name[s]  (Given name[s])

____________________________
Last Name[s]  (Family  name[s] or surname[s])

Address 1:_____________________        Phone:________FAX: ________ 

Address 2:_____________________          E-mail:_______ URL:_________

City:_________________State:______ 

Zip/Postal Code:_______ Country:___________    Area of Interest:______ 
             Please indicate type of membership:

Student Membership (include verification)

($20.00)

Full Membership

($40.00)

Corporate Membership

($250.00)

Sustaining Membership

($100.00)

Institutional Subscription

($ 50.00)

Tax-deductible donation for:

 

      Student awards/travel

$ _______

      other (                        )

$________

      unrestricted

$________

   Total enclosed  $_______   Check payments must be made in U.S. dollars and drawn on a U.S. bank. Visa and MasterCard (only)  accepted.

Credit Card Type___      Card #_______________ Exp. Date____