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Membership Application (PDF format)
If you have trouble downloading the PDF membership application, you may print out this page and use it to apply for membership.
Membership Form
Our Membership / Subscription year begins January 1. All memberships are for a calendar year from January 1 to December 31. We strongly encourage members to renew during the Fall months for the upcoming year. Please send your dues to
HSA Secretary
Angela Terry
18036 49th PL NE
Lake Forest Park, WA 98155-4314
<hsa-9at@comcast.net>
Membership Year
_____ 2013
_____ 2014
Membership Status
_____ New
_____ Renewing
Regular Membership
_____ $35 United States
_____ $37 Canada and Mexico
_____ $47 Other countries
_____ $30 North America senior (65 and over)
_____ $30 North America full-time student
Special Membership
_____ Over $35 Friend
_____ $50+ Donor
_____ $100+ Sponsor
We are especially grateful to those who choose membership in special categories; It is difficult to meet our publication and mailing expenses on income from standard memberships only.
Donation to Special HSA Initiatives
HSA Education Fund (indicate amount donated): $_______________
HSA Scholarship Fund (indicate amount donated): $_______________
Payment method
_____ Check
_____ Money Order
_____ Cash
_____ PayPal
______________________________________
Name
Please make checks payable to Haiku Society of America. Please write Postal Money Orders to Haiku Society of America, c/o Paul Miller, Treasurer.
Canadian and Overseas Members: Personal checks in U S funds are acceptable if your bank has an affiliate in the U S. If not, please use a Canadian or International Postal Money Order in U.S. funds and write it to Haiku Society of America, c/o Paul Miller, Treasurer.
______________________________________
Address
______________________________________
City
____________________________-_________
State ZIP
______________________________________
Phone
______________________________________
E-mail
_____ I would like my mailing address included in the HSA Newsletter and annual Directory.
_____ I would like my E-mail address included in the HSA Newsletter and annual Directory.
_____ I don’t want my mailing or E-mail address included in the HSA Newsletter and annual Directory.
If left unchecked, your mailing and E-mail addresses will be included in the HSA Newsletter and annual Directory.
_____ Yes, I’d be willing to volunteer for the HSA. We rely on volunteers for numerous jobs. If you have expertise in publicity, education, teaching, publications, database management, website design, or in any other field that might benefit the organization, please indicate your areas of expertise below.