Name: ____________________________________________________________

Mailing Address: ___________________________________________________

Mailing City: ____________________ Mailing State or Province: ______________

Zip or Postal Code: _________________ Country: __________________

Telephone (home/office/fax): _________________________________________

Electronic Mail Address: ____________________________________________

Check all that are applicable

• New Membership
• Renewal
• Gift Membership (please enter your name and address at the bottom of the form)

Membership Class (check one):

• Individual- $35.00
• Household/joint- $40.00 (Please include name of spouse - one set of publications)
• Full-time Student- $20.00 (Must attach copy of current full time Student ID)
• Contributing- $75.00 (May include spouse as joint contributing member - one set of pubs)
• Sustaining- $125.00 (May include spouse as joint sustaining member - one set of pubs)
• Institutional- $50.00 (Please include primary institutional contact name on form)
• Corporate- $500.00 (Please include primary corporate contact name on form)

Members outside of US and Canada please add $10 for additional surface mailing charge.

Additional Contribution (For Scholarships, Vogel Prize Fund, Preservation Grant Fund or General Fund): ______________

Make checks payable to Society for Industrial Archeology. (Checks must be in U.S. dollars and drawn on a U.S. bank)
If paying by credit card, please include:

Name of Cardholder:_________________________Circle type of Card (MC, VISA or Discover)

Account Number: ____________________________ Expiration Date (MM/YY): ____________ CVV2 : ______

Note about CVV2. An important new security feature for online and other "card-not-present" transactions now appears on recently issued Visa, Mastercard, and Discover credit cards. The CVV2 three-digit value is printed on the signature panel on the back of your credit card immediately following the card account number. CVV2 is only printed on your credit card — it is not contained in the magnetic stripe information, nor does it appear on sales receipts.

Signature: _______________________________________________________

We CANNOT process your credit payment unless all information is COMPLETE and LEGIBLE!

Make a hardcopy of this form, fill it out, and send it with your payment to:
Society for Industrial Archeology
Department of Social Sciences
Michigan Technological University
1400 Townsend Drive
Houghton, MI 49931-1295 USA