Title         : MrMrsMsDr 
First Name    : 
Middle Name   : 
Family Name   : 
Email         : 
Please confirm your 
email address : 

Print your name here as to be shown on your membership card.
                

Home Address  :
                

Home Phone No.: 
Home Fax No.  : 
Profession    : 
Job Title     : 
Place of Birth: 
Date of Birth : 
Nationality   : 
Passport No.  : 
(This personal information is kept strictly confidential 
and used for the issue of your membership material.)

Business Address
Company Name  : 
Address       :
                

Phone No.     : 
Fax No.       : 
Email.        : 
I prefer my communications at my :
                Business Address.
                Home address. 

TO EXPEDITE your application, complete and submit this form or, print and 
email your enrollment form to us. We will process your membership within 
24 hours (subject to credit card approval)

Please charge my membership fee to the following credit card :


First Choice  : AMEXVISAMASTERCARD
Credit Card No: 
Exp. Date     : 

Second Choice : AMEXVISAMASTERCARD
Credit Card No: 
Exp. Date     : 
Name as it appears on your credit card and billing address :
Name          : 
Address       :
                

City          : 
State         :   Zip  : 
Country       : 

Internet Membership Renewals are automatically renewed to your 
credit card annually. Twenty one days prior to the expiry of your 
membership and prior to charging the renewal fee to your credit card, 
we will contact you to remind you that your membership is due for 
renewal and advise you of the credit card renewal charge. At this time 
you can change the status of your membership if you wish.

Do you wish to be reminded 21 days prior to renewal date:  NoYes

Date          :