Python Software Activity Registration

Please Type or Print                     ___Renewal  or  ___New Member

Name (Dr|Mr|Ms) ______________________________________________________

Organization _________________________________________________________

Address ______________________________________________________________

        ______________________________________________________________

City ____________________________ State ______ Postal Code ___________

Email ___________________________ Phone _____________ FAX ____________

Indicate your payment and membership type, and submit it as follows:
• Make checks payable to CNRI. The check must be U.S. dollars drawn on a U.S. bank.
  Send membership registration with payment to:
  Corporation for National Research Initiatives
  ATTN: Accounting Department - PSA
  1895 Preston White Drive, Suite 100
  Reston, VA 20191-5434
  
• You can FAX credit-card based memberships: (703) 620-0913.
• Please do not send credit information via email - we do not have provisions for secure transmission.
• No phone orders, please.

     Individual                        ___ $  50
     Corporate Associate               ___ $ 650
     Corporate Sponsor                 ___ $1300
     Employee of Corporate Member      ___ $   0

Payment type (circle one):    Check    Visa    MasterCard    AMEX

Card Account No _________________________  Expiration Date  ______   EXTRA
                                                                     LEGIBLE
Cardholder Name __________________________________________________   PLEASE!

Cardholder Signature _____________________________________________