AMSAT® President's Club

Radio Amateur Satellite Corp.
850 Sligo Ave., Suite 600
Silver Spring, MD, 20910-4703 USA
martha@amsat.org ... fax +1(301)608-3410

Donation Form

To: AMSAT

Please sign me up for the AMSAT President's Club. I understand that I may pay the total sum by check or VISA/MasterCard or I can choose to be charged monthly to my VISA/Mastercard as indicated below.

Name: _________________________________________ Call Sign:____________

AMSAT Member Number: ___________ (if known)

Address: ____________________________________________________________

City: __________________________ State / Province: ________

ZIP/Post code: _______________ e-mail address: ________________________

Gold Donor: [_] US$100 per month by VISA or MasterCard or
[_] US$__________ one time check or charge (at least US$1200)
Silver Donor: [_] US$50 per month by VISA or MasterCard or
[_] US$__________ one time check or charge (at least US$600)
Bronze Donor: [_] US$25 per month by VISA or MasterCard or
[_] US$__________ one time check or charge (at least US$300)
Core Donor: [_] US$10 per month by VISA or MasterCard or
[_] US$__________ one time check or charge (at least US$120)

VISA or MasterCard Card Number: ______________________________ Exp. ____________

Daytime Telephone Number _____________________________ (if paying by card)

Signature: ________________________________________ Date: ___________

2002.12.12