GOPIO MEMBERSHIP APPLICATION FORM

Please fill the form below and send it with a check to GOPIO, P.O. Box 1413, Stamford, CT 06904, US

Name(s)___________________________________________Tel______________

Organization/Company(Optional)_____________________________Fax:_______________

Address___________________________________________________E-mail_____________

City_______________________State___________Zip___________Country_____________

I want to become a member of GOPIO

Enclosed is a check/money order for__ $1000 as a Life Member or __ $50 as Local Chapter Membership (annually)