AMIDA WEST:Membership Application

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A M I D A � W E S T

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Affiliation Membership - North America

To become a member just fill out the form below and mail a check or money order in U.S. dollars to:
AMIDA WEST
3506 Blue Bonnet
Houston, Texas
U.S.A. �77025
When we receive your check, your membership will be activated and you will receive a return email acknowledging receipt of your joining.

A P P L I C A T I O N � F O R M

Please enroll me as a Member of Amida Trust. I will be sending my yearly membership donation as selected below.

Select whether this is a: "New Membership" or a "Membership Renewal" Select which membership type you are applying for:
�	Associate Member $26 Supporting Member $40 Sustaining Member $150

NOTE: Fields marked with a * are compulsory.

* Name:
Address:
City:
State:
Country:
Zip:
Phone:
Fax:
* Email:

I also wish to join the Trust's psychotherapy division & IBAP, and will enclose an additional $2.00 U.S. If you have any of the following special interests please check them off:
�	Buddhist approaches to child care to work in clinical settings arts working with death & dying community mental health humanitarian aid East Europe

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Email Amida West

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