Institute for Molecular Manufacturing
Senior Associate Membership Application

and fax or mail this form to:
Institute for Molecular Manufacturing
555 Bryant Street, Suite 354
Palo Alto, CA 94301 USA
Tel: 650-917-1120 Fax: 650-917-1120

Yes, I want to join the nanotechnology effort by becoming a Senior Associate. This donation is for a
  new membership     continuing membership.    renewal after fulfilling a 5-year pledge
Send me the Senior Associate Letters and invite me to the annual gathering. My pledge is at the following level:
Associate $250 annually for five years.
Fellow $500 annually for five years. Includes signed gift book.
Colleague $1000 annually for five years. Includes framed signed artwork.
Friend $5000 annually for five years. Includes engraved crystal "Friend of IMM" award on ebonite base and the signed framed artwork.
This gift is an: Individual contribution Corporate contribution
A matching gift will be made by my company

Name: _______________________________________________

Address: ______________________________________________

City, State: ____________________________________________

Zip Code/Postal Code, Country: ___________________________

Phone: __________________________ Fax: __________________________

Email: _______________________________________________

My first annual donation is enclosed, payable to the Institute for Molecular Manufacturing. IMM is a nonprofit foundation; donations are tax-deductible in the U.S. to the full extent permitted by law. Donations can be made by check from a U.S. bank, postal money order, VISA, or Mastercard. Credit card donations may be sent by fax.

Name as it appears on credit card:_________________________________

VISA or Mastercard Number:_______________________

Expiration Date:_______________________

Signature _______________________________________

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Last updated 7October2000. The URL of this document is:
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