Name _________________________________________________________

E-Mail Address _______________________________________________

Address ______________________________________________________

        ______________________________________________________

City   ___________________  State ________ ZIP _______________

Phone (______) ___________________   [ ]Home  or  [ ]Work ?

Profession ___________________________________________________

Employer______________________________________________________

 [ ]  One year Membership                    - $50
 [ ]  One year Student Membership     - $25
 [ ]  One year Senior Membership        - $25

 DONATIONS Gladly accepted:
 [ ]  Donation - $100
 [ ]  Donation - $500
 [ ]  Donation - $1000

. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
Method of Payment - [ ] Check           [ ] Money Order
                    [ ] Credit Card     [ ] P.O. (on approval)

Credit Card Type [ ]Visa  [ ]Mastercard  [ ]Discover  [ ]Am Ex

Number on Credit Card ________________________________________

Name as it appears on card ___________________________________

Expiration Date ____________________

I authorize The Mars Society to bill the above fee(s)

to the above credit card. Total = _______________
 

____________________________________________
     Signature

Print this form, fill it out, and send it along with payment to:

                Mars Society
                Box 273
                Indian Hills, CO 80454

Credit card orders can be FAXed to (303) 980-0753