IASD Membership Form To join IASD or renew your membership, please complete this form. Remember that membership in IASD entitles you to a significant reduction in the annual conference and regional meeting fees. [ ] New Member or [ ] Renewing Member How did you hear about IASD? Membership Type [ ] Individual - $100.00 [ ] Student -$65 (send photocopy of picture ID verifying full-time student status) [ ] Limited Income - $65 (under $22,000 annual income) [ ] Patron -- $150 (or more if you wish) [ ] Couple - $150 (living at one address, receive one copy of each publication) ------------------------------------------ Credit Card Number : Amount on Credit Card : Expiration month and year : ---- Amount sending in via Check or Money Order: Make checks (U.S. funds only) payable to IASD. If you are mailing in a check, print this form and send with check to: Membership Richard Wilkerson IASD Central Office, 4644 Geary Blvd PMB 171 San Francisco, CA 94118 ---- Name on Credit Card Street Address where credit card is billed Street Address 2 if needed City State Province or Territory if needed Zip or Postal Code Country E-mail Please repeat E-mail Day Phone Evening Phone Fax Website [ ] Use the above address and information for my Membership information as well. or [ ] Use the address below for my Membership address info ---------------------------------------- Membership Information if different from Credit Card information: Name Street Address Street Address 2 if needed City State Province or Territory if needed Zip or Postal Code Country E-mail Please repeat E-mail Day Phone Evening Phone Fax Website ----------------------------------------------------------------------------------------- Give a Gift? Gift Membership Type [ ] Individual - $100.00 [ ] Student -$65 (send photocopy of picture ID verifying full-time student status) [ ] Limited Income - $65 (under $22,000 annual income) [ ] Patron -- $150 (or more if you wish) [ ] Couple - $150 (living at one address, receive one copy of each publication) --------------- Gift Recipient's Name Gift Recipient's Street Address Gift Recipient's Street Address 2 if needed Gift Recipient's City Gift Recipient's State Gift Recipient's Province or Territory if needed Gift Recipient's Zip or Postal Code Gift Recipient's Country Gift Recipient's E-mail Gift Recipient's Please repeat E-mail Gift Recipient's Day Phone Gift Recipient's Evening Phone Gift Recipient's Fax Gift Recipient's Website --------------------------------------------------- Pledge to IASD I want IASD to realize its dreams. Please accept my pledge of [$ ] to be donated each quarter for operating expenses and new programs. I enclose my first payment of [$ ] I want to make a one time contribution of [$ ] to: [ ] IASD Publications [ ] Conference Scholarship Fund [ ] The Nightmare Hotline My total contributions place me in the category of: [ ] Hypnagogic Donor $100-$500 [ ] REM Donor $501-$1,000 [ ] Lucid Donor $1,000+ I am willing to have my name published on the ASD Donor page online: [ ] Yes [ ] No ----------------------------------------------------------------------------- Membership fee total $ Gift Membership fee total $ Donation total $ Total $ ------------------------------------------------------------------------------ [ ] Check this box if you do not want your name included for distribution on the ASD Membership List? Occasionally, IASD provides a list of current members to organizations who wish to market books and other dream-related materials. To remove your name from such a list please check this box: [ ] If you have other comments or communications with the Central Office, please write them here. Please return this form with check or credit card information to Membership Sue Moreno IASD Central Office, P.O. Box # 1592 Merced, Ca. 95341-1592 ------------------------------------------ Questions? Contact Richard Wilkerson Phone: 1-209-724-0889 E-Mail office@ASDreams.org -----------------------------------------