Membership Application - Outside U.S.
The Amazona Society
235 North Walnut Street, Bryan, Ohio, U.S.A. 43506

New  Membership              Renewal 

Name:                                                                                                      

Address:                                                                                                   

City:                                               State/Province:                                   

Country:                                         Postal Code:                                      

Phone:                                            Fax:                                                   

E-mail:                                                                                                     

A one year membership is: $26.00 U.S. for outside the U.S.A.

Please check applicable payment method:

  bank draft in U.S. dollars is enclosed.

Mastercard          Visa

Card Number:                                                                                         

Expiration Date:                                                                                      

Name as it appears on the card:                                                               

Authorized Signature:                                                                              

Please note: Credit card charges will appear on your statement as the SRT Prosthetics which is
generously offering this service and will transfer your payment to The Amazona Society.

Thank you for joining!