UNA-USA Membership Application

___ $25---------------------introductory (1st year only)

___ $35---------------------individual

___ $40---------------------family

___ $40---------------------organization / school / business

___ $10---------------------student

___ $20---------------------limited income individual

___ $25---------------------limited income family

___ $100--------------------sponsor

___ $500--------------------patron

___ $1,000-----------------benefactor

Status:

___ new ___ renewal

Membership Type:

___ personal ___ local organization / school / business

(contributions are tax deductible to the extent provided by law)

_________________________________________________
name (please print)

_________________________________________________
address

_________________________________________________
address

_________________________________________________
city / state / zip

_________________________________________________
home phone

_________________________________________________
business phone

_________________________________________________
e-mail

Please print this form, fill it out, enclose your check payable
to UNA-USA, and mail to:

UNA-USA Membership Services
801 Second Avenue
New York, NY 10017-4706

phone: 212-907-1300
fax: 212-682-9185