Global Network - Membership Form

CONTACT:

Bruce K. Gagnon
Secretary/Coordinator
Global Network Against Weapons & Nuclear Power in Space
PO Box 652
Brunswick, ME 04011
USA
Phone: (207) 443-9502
or by e-mail ( globalnet@mindspring.com ).

GLOBAL NETWORK MEMBERSHIP FORM FOR 2012

Membership in the Global Network Against Weapons & Nuclear Power in space is open to all organizations and individuals.

Donations made by U.S. citizens to the Global Network are tax-deductible.

Please add ______________________________
to the Global Network membership list.

Enclosed is our annual dues for 2012 in the amount of _____________
(pay what you can best afford on a sliding scale between $10 - $100)

Name________________ Address_________________

City_______________

State_____________ Zip/Postal Code_____________

Country____________

Phone ( )_____________ E-Mail______________

Fax ( )_____________

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