_Name:

_Affiliation:

_{Mailing address:}

_Telephone:

_office:

_home:

_Telefax:

_E-mail:

                                           AGE: ______________________  GENDER____________________________

_{A. Membership fees:}

_{$25 US per year}
 

_{(from personal resources)}

_{$ 75 US per year}
 

_{(from institutional resources)}

I will pay for

_{(from personal resources):}

_{(  ) $25 US for 2006}

_{(  ) $50 US for 2006-2007}

_{(  ) $75 US for 2006-2008}

I will pay for

_{(from institutional resources):}

_{(  ) $75 US for 2006}

_{(  )  $150 US for 2006-2007}

_{(  ) $225 US for 2006-2008}

_{ I am unable to pay the fee, but wish to become a member.}

_{Renewal only: In addition to the payments above, I am also paying  for: (  ) 2000  (  ) 2001   (  ) 2002   (  )  2003  (  )  2004 (  )  2005}

_{Total amount to pay:                                   USD}

_{B. Payment (Please, prefer the Visa/MasterCard alternative if possible).}

Please charge my  (  ) Visa  (  ) MasterCard no.[2]:

_{Expire date:}

Name of the cardholder/Signature :

                                                            _{Alternative ways to pay:}          

_{Direct Deposit to bank accounts:}

_{Checks made payable to “Kettil Bruun Society” to:}

Kettil Bruun Society / SIRUS

Nordea Bank Norway

Postbox 1166, Sentrum

0107 Oslo, Norway

Account No. 6080.05.28685

Elin K Bye

SIRUS, POBOX 565

0105 Oslo, Norway