Please check one of the following membership types:
[ ]
Corporate.............................................................$100.00
[ ] Friend
.................................................................$75.00
[ ] Non-profit Organization...........................................$60.00
[ ] Contributing...........................................................$50.00
[ ] Family....................................................................$30.00
[ ] Individual................................................
............$20.00
[ ] Full Time Student....................................................$15.00
Mr./Mrs./Ms:____ First Name_____________ Last
Name:_______________
If family/Corporate/Non-profit membership, please list
members names:
Mr./Mrs./Ms:____ First Name:____________ Last
Name:________________
Mr./Mrs./Ms:____ First Name:____________ Last
Name:________________
Mr./Mrs./Ms:____ First Name:____________ Last
Name:________________
Address__________________________________________________________
_________________________________________________________________
Town: _________________________ State:_____ Zip
Code:______________
Home Phone:___________________ Work
Phone:______________________
Would you like to help JASC by participationg the
committee meeting?
Yes__ No__
I would like to make an additional contribution to the:
JASC Scholarship Found of $___________
General Found of $___________
Total with membership enclosed $___________
Please complete the form above and send with a check
payable to JASC to the following address:
Japan-America Society of Connecticut
PO Box 755
Avon, CT 06001
USA