Membership Application Form

Please print this out and snail mail or email it to:

Your Name __________________________________________________________________________ Age ______

Date of Birth ______________

Address _________________________________________________________________________________________

_________________________________________________________________________________________

City _______________________________ State ______________

Zip Code ___________ Country ____________________________

Phone Number (with Area Code) ____________________________

E-mail address ___________________________________________

Where did you hear about us ________________________________________________________

Where do you attend school (Student Memberships Only) ______________________________

Where do you teach (Educators Only) ________________________________________________

What are your intersests in Herpetology ____________________________________________

Do you have any special skills or background that might be of interest to our membership or which you would like to use to help the HSS: ____________________________________________________________________________________

Would you be willing to participate in our rescue program?

___Yes ___ No

What types of animals would you be willing to house?

_________________________________________________________________________________________

Membership: (Check One)

_____ Individual (SGD$35.00/year)

_____ Students and Educators (SGD$28.00/year)

Outside of USA:

_____ USA, Canada and Mexico (SGD$50.00/year)

_____ Europe (SGD$55.00/year)

_____ Australia, New Zealand, Japan (SGD$48.00/year)

_____ Rest of World ($50.00/year)

The names, phone numbers, and interests of all new members are routinely published each month in the HSS News. This information is also recapped annually in our Membership Directory and Resource Guide. Please check as indicated if you wish to modify this:

_____ Please do not publish my name

_____ Please do not publish my interests

_____ Please do not publish my phone number

_____ Please do not publish my e-mail address

_____ Please also publish my address