Individual Member's
Name _____________________________________
Organization (if
any) __________________________________________
Institution or
Company ________________________________________
Address ___________________________________________________
_________________________________________________________
City __________State/Province
__________ Zip/Postal Code __________ Country __________
Telephone __________
Fax __________ Email Address ____________________
Cash Enclosed
$ __________Check payable to USWC $__________________
To Pay by Credit
Card $_______
Cardholder's Name____________________
Expiration Date_______
MasterCard/Visa (circle one)Card #_____________
Cardholder's Signature___________________________________________
