Frist Name    Last Name

Address

Telephone   Fax email

Citizenship: USA    Outside of USA (please specify nation)

Ethnic Origin (Check all that apply)    African Asian Latino Hispanic Indigenous European Other American

Major Faith Identification Christian Jewish Muslim Buddhist Hindu Indegenous      Denomination:

Occupation:

Institutional Affiliation:

Type: Seminary Undergraduate Education Research University Secondary/High School Ecclesial Institute Other

Renew my membership for:

  $35 - income < 25,000                           $75 - income from 40,000- 54,999

$60 - income from $25,000 - $39,999       $85 - income from 55,000- 64,999

$95 - income > 65,000

I have also included a donation of :  Total payment:

PAYMENT INFORMATION:

Credit Card #    Expiration date (mo/yr):