SOCIEDAD WESLEYANA

MEMBERSHIP APPLICATION

_____New Member ____Membership Renewal ____New Contact Information

Annual Membership Dues:

_____$25 Student ____ $30 Individual ________ $100 Institutional Membership

Please include a check or money order made payable to the Sociedad Wesleyana and mail to:

Title:____________

Name: ___________________________________________________________

Address: _________________________________________________________

City: _____________________________ State/Province: ___________________

Zip: _________________

Country: __________________________________________________________

Institutional Affiliation: ________________________________________________

Phone: ___________________________________________________________

E-Mail: ___________________________________________________________

Website / webpage__________________________________________________

Other Contact Information: ____________________________________________

______  Please include me in the SW Members mailing list.

I am interested in the following work area(s):

___ Renewal of the church local, national, global

___ Networking

___ Education and Teaching

___ Scholarship and Research

___ Grants and Fundraising

___ Writing, Publishing, and Translating

___ Distribution

Signature:________________________________________________________

Date: ______________________________