Foresight Institute
Membership Application

 PLEASE PRINT
and fax or mail this form to:
Foresight Institute, Box 61058
Palo Alto CA 94306 USA
Tel: 650-917-1122 Fax: 650-917-1123

As an informed individual you already understand the immense potential and possible perils of nanotechnology. Foresight Institute needs your help to continue our work in educating the general public and guiding this technology for the benefit of society and the environment. Thank you for your support.

Enclosed is my contribution to the Foresight Institute for a:

empty box to checknew,   or   empty box to checkcontinuing $60 membership.   empty box to checknot a membership, but another donation for:
         purpose of this donation: __________________________
   amount of this donation: $________
empty box to check I'd like to help Foresight Institute do more. Enclosed is an additional tax-deductible contribution of $________   If you would like to donate $250 or more per year, please consider Foresight's Senior Associate Program.
empty box to check A matching gift will be made by my company  
Foresight is a 501(c)3 nonprofit organization. Donations are tax-deductible in the U.S. to the full extent permitted by law.

Name: _______________________________________________

Address: ______________________________________________

City, State: ____________________________________________

Zip Code/Postal Code, Country: ___________________________

Optional Information:

Work Phone: __________________________ Home Phone: __________________________

Fax: __________________________Email: _________________________________

Name as it appears on credit card:_________________________________

VISA or MasterCard Number:____________________________

Exp. Date:___________ Month/Year

Signature ________________________________

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Last updated 3 September 2004. The URL of this document is: http://www.foresight.org/about/Donation.html