It should be noted that we will only accept American Express, Master Card or Visa credit cards and all contributions will be made in US Dollars. When you have completed this contribution form, please press the Continue to Secure Payment Form button. You will be transferred to a secure web site where you will be required to enter your credit card information.

          Please press the button to indicate the amount that you or your organization wishes to contribute to the Society. (Note you will only be able to select just one button.)

            Contribution of $25.00

            Contribution of $50.00

            Contribution of $75.00

            Contribution of $100.00

            Contribution of $250.00

            Contribution of $500.00

            Contribution of $1000.00

     Contribution Information (Please complete the following)

     Your full name:    As it appears on credit card

     Contributor:         Enter the name that you wish to have appear on the List of                                                                            Contributors

      Street Address:

     Suite or Apt.:     

     City:                       

     State:                   Select State AlabamaAlaska ArizonaArkansas CaliforniaColorado ConnecticutDelaware District of Columbia Florida Georgia Hawaii IdahoIllinois IndianaIowa KansasKentucky LouisianaMaine MarylandMassachusetts MichiganMinnesota MississippiMissouri MontanaNebraska NevadaNew Hampshire New Jersey New Mexico New York North Carolina North DakotaOhio Oklahoma Oregon Pennsylvania Rhode Island South CarolinaSouth DakotaTennesseeTexas UtahVermont VirginiaWashington West VirginiaWisconsin Wyoming  US residents only (Residents of Puerto Rico please see Caribbean)   

    Outside US:            (State or Province outside the United States)  
                                                                              Format: State or Province
                                                                              Example: Quebec

     Zip Code:              If your country does not use zip codes leave this box blank

     Country                  US residents use "US". Residents of other countries and Puerto Rico,                                          please find and  click on name of your country from the following pull down lists.

                Africa                                                  Asia                                                   Australia    
     Select CountryAlgeria BeninBotswana Burkina FasoBurundi CameroonCape Verde Central African RepublicChad Comoros Congo Cote D'Ivoire Djibouti EgyptEquatorial Guinea Eritrea Ethiopia Gabon Gambia GhanaGuinea Guinea-BissauKenya LesothoLiberia MadagascarMalawi MaliMauritania MayotteMorocco MozambiqueNamibia NigerNigeria ReunionSao Tome and Pricipe Senegal Sierra Leone Somalia South Alrica St. Helena Sudan SwazilandTanzania TogoTunisia UgandaWestern Sahara ZaireZambia Zimbabwe                      Select Country AfghanistanBangladesh BhutanBrunei CambodiaChina Hong KongIndia IndonesiaJapan KazaldistanKyrgyzstan LaosMacau MalaysiaMaldives MongoliaNepal PakistanPhilippines Republic of Korea Russia Seychelles Singapore Sri Lanka Taiwan Tajikistan Thailand Turkmenistan Uzbekistan                Select Country American SamoaAustralia Federated States of MicronesiaFijiFrench Polynesia GuamKiribati Marshall IslandsNaurn New CaledoniaNew Zealand Northern Mariana IslandsPalauPapua New Guinea PitcairnSolomon Islands TongaTuvalu Vanuatu      

                  Caribbean                                 Central America                                       Europe                
     Select CountryAnguilla Antigua and Barbuda Aruba BahamasBarbados BermudaCayman Islands DominicaDominican RepublicGrenada GuadeloupeHaiti JamaicaMartinique Netherlands AntillesPuerto Rico St. Kitts and NevisSt. LuciaSt. Vincent and the Grenadines Trinidad and TobagoTurks and Caicos IslandsVirgin Islands - British Virgin Islands - U.S.           Select Country BelizeCosta Rica El SalvadorGuatemala (GT) HondurasNicaragua Panama                    Select Country AlbaniaAndorra ArmeniaAustria AzerbaijanBelarus BelgiumBulgaria CroatiaCyprus Czech RepublicDenmark EstoniaFaroe Islands FinlandFrance GeorgiaGermany GibraltarGreece GreenlandHungary IcelandIreland ItalyLatvia LiechtensteinLithuania LuxembourgMacedonia MaltaMetropolitan France Moldova Netherlands Norway Poland PortugalRomania SlovakiaSlovenia SpainSvalbard and Jan Mayen IslandsSwedenSwitzerlandTurkey UkraineUnited Kingdom Vatican City Yugoslavia  
     

               Middle East            North America          South America                           Others
     Select CountryIsrael JordanKuwait LebanonOman QatarSaudi Arabia SyriaUnited Arab Emirates Yemen         Select CountryCanada Mexico         Select CountryArgentina BoliviaBrazil ChileColombia EquadorFalkiand Islands French Guiana Guyana ParaguayPeru SurinameUruguay Venezuela          Select Country BahrainBouvet Islands British Indian Ocean TerritoryChristmas IslandsCocos Islands Cook Island East Timor French Southern TerritoriesMcDonald IslandsMauritius MonacoMontserrat MyanmarNiue Norfolk IslandSamoa San MarinoSt. Pierre and MiquelonTokelau US Minor Ouflying IslandsFutuna Islands

     Telephone No.  

     Fax No.              

     E-Mail Address:

Please check your Contribution Form. Make sure you have completed ALL appropriate sections. Printout a copy of the form for your records. You may make corrections by pressing the Reset button and re-enter your information. To submit your contribution just click on the Continue to Secure Payment Form button.