Membership Application Date: ______________ First Name: ________________________ Last Name: __________________________ Address: _______________________________________________________________ City: _______________ State or Province: _________ Postal code: _____________ Country: ___________ E-mail: ___________________________________________ Telephones Home: ___________________ Work: ___________________ Mobile: __________________ Fax: ____________________ What is your occupation? ___________________________________________________ What is your website address? (If you would like it listed) __________________________ Would you like to be listed in the online members-only membership list? Yes ___ No ___ What would you like your User Name and Password to be for the NACS website? User Name _____________________ Password ______________________ Type of Membership: New ______   Renewal _____   Gift ______ * Level of Membership (membership is form January to December): Please Specify intended year of membership __________ Individual or Household @ US$20 for one year ______ Individual or Household @ US$50 for three years ____ I would like make an additional contribution to the North American Clivia Society in the amount of US$ ___________________ Method of payment: □Check or Money Order   □Mastercard   □Visa Checks should be made out to N.A.C.S. Overseas participants must pay in US $ or by credit card. Card Number: ________  ________  ________  ________ Exp: ___/___ Signature __________________________________ Date __________________ Mail this application with your payment to: North American Clivia Society PO Box 1808 Camarillo, CA 93011 U.S.A. * If this is a gift membership, please write your name and address below. Thank you! First Name: ________________________ Last Name: __________________________ Address: _______________________________________________________________ City: _______________ State or Province: _________ Postal code: _____________ Country: ___________ E-mail: ____________________________________________ Telephone: ____________________________ If you would like to volunteer, please describe how: ______________________________ _______________________________________________________________. Thank you! Application Revised on 29 September 2005