Print and Mail to SEMC, PO Box 9003, Atlanta, GA 31106-1003 or fax: 404-370-1612.   SEMC FEIN ID# 54-1042825.  Questions? 404-378-3153

Name:______________________________________________________________

Position:____________________________________________________________

Institution:__________________________________________________________

Address:____________________________________________________________

City/State/Zip________________________________________________________

Phone:______________ Fax:______________ E-mail:________________________

MEMBERSHIP CATEGORIES (PLEASE CHECK ONE):

_____ $150 Independent Professional

_____ $350 Business Associate

_____ $1,900 Corporate Partner

_____ $2,800 Corporate Underwriter

_____ $4,000 Preferred Corporate Partner

A special gift of $_________ is enclosed to help support SEMC's endowment.

[ ] Check Enclosed (payable to SEMC)

[ ] I wish to pay with my credit card.  [ ] Mastercard  [ ] Visa  [ ] AMEX  [ ] Discover

Card # ___________________ Expiration Date: ___________

Signature:__________________________________________
(required for all credit card charges)