2010 Institutional Membership Form
Please note that, for all USAIN members, the membership year is from January 1 to December 31. Membership dues are not pro-rated.
Primary Member
First-time member_______ Renewing member_______
Name:______________________________________________________
Organization:________________________________________________
Title:______________________________________________________
Mailing address:_____________________________________________________
_________________________________________________________________
_________________________________________________________________
Phone:________________________ Fax:______________________________
Email:____________________________________________________________
USAIN Interest Groups
Check any you would like to join. There is no additional charge for Interest Groups.
_____ AgNIC
_____ Animal Health Information
_____ Collection Management
_____ International Agriculture
_____ Social Issues / Rural Information
_____ Technology Trends
USAIN Listserv
I am already subscribed to USAIN-L _____Yes, please add me to USAIN-L at the email address listed above _____
No thank you. I do not wish to subscribe at this time _____
Secondary Member
First-time member_______ Renewing member_______
Name:______________________________________________________
Organization:________________________________________________
Title:______________________________________________________
Mailing address:_____________________________________________________
_________________________________________________________________
_________________________________________________________________
Phone:________________________ Fax:______________________________
Email:____________________________________________________________
USAIN Listserv
I am already subscribed to USAIN-L _____Yes, please add me to USAIN-L at the email address listed above _____
No thank you. I do not wish to subscribe at this time _____
USAIN Interest Groups
Check any you would like to join. There is no additional charge for Interest Groups.
| _____ AgNIC | _____ Animal Health Information |
| _____ Collection Management | _____ International Agriculture |
| _____ Social Issues / Rural Information | _____ Technology Trends |
Annual Institutional Membership Dues
$250.00_____Institutional (includes a primary member and a secondary member.)
Payment Information
_____Check Enclosed (Make payable to USAIN)
_____Institutional Purchase Order __________________________________
Credit Card No. (Visa or Mastercard)_______________________________ Exp. Date _____
Security Code on back of card ____
Cardholder's Name:______________________________________________________ (as it appears on the card)
Billing address (on the account): _______________________________________________
______________________________________________________________________
Signature______________________________________________________________
Mail to:
USAIN Membership
Chris Long & Associates
P.O. Box 117
West Milton, OH 45383
voice: 937-698-4188
fax: 937-698-6153