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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.

Dues are due on or before December 31 for the coming year. Delivery of the first issue of Frogpond for the next year will be delayed for members paying dues after December 31.


 

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
Mollie Danforth
4016 Harris Place
Alexandria, VA 22304
<hsasecretary2014@gmail.com>

Membership Year
_____ 2014
_____ 2015

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.



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