==========================================================================
INTERNET
SOCIETY

                                                           24 Feb 1994

           Application for Individual Membership - Template

__  Please enroll me as an individual member of the Internet
    Society.  I understand that membership in addition to fostering
    the evolution of the Internet and its use, entitles me to
    receive the quarterly Internet Society News, reduced fees for
    attandance at Internet Society conferences and other benefits.
    Membership will extend for 12 months from the month of
    application receipt.  I am applying for:

    __ Individual membership at $35.00

    __ Student individual membership at $25.00

__  Please send me additional information on the Internet Society

    Name: __________________________________________________________

    Postal Address:
  
                   _________________________________________________

                   _________________________________________________

                   _________________________________________________

  
  Internet Email address:  _________________________________________

  Fax (optional) : ____________ Telephone (optional):  _____________

Payment Information:

 Payment of annual dues may be made by check, money order, credit
 card or wire transfer.

 ___ Payment is included with this application  __  Please bill me

 For credit card payments:

 __ VISA   __ Master Card   __ AMEX    __ Diner's Card  __ Carte Blanche

 Card Number:      ____________________________

 Expiration Date:  ____________________________

 Signature:        ____________________________

Send wire transfers to:

 Riggs Bank of Virginia     Bank ABA number: 056001260
 8315 Lee Highway           Account number: Internet Society 148 187 10
 Fairfax  VA  22031
 USA

Please send by post, fax or email to:

 Email: <membership@isoc.org>

 Fax: +1 703 620 0913 (until 12 Mar)
 Fax: +1 703 648 9887 (after 12 Mar)

 Tel: +1 703 648 9888

 (until 12 March 94)    (after 12 March 94)
 Internet Society       Internet Society
 1895 Preston White Dr  12020 Sunrise Valley Dr #270
 Reston  VA  22091      Reston  VA  22091
 USA                    USA

                                                       Form 94-001 v.1.1
==========================================================================