E-Vam Buddhist Institute
                                      Membership Form
						 
Type of membership:

____ Sustaining Member $1,200 or $100 monthly

____ Family Membership $600 or $50 monthly

____ Full Member $420 or $35 monthly

____ Associate Member $180 or $15 monthly


Your name: ............................................................................... Date: ....................

Principle Address: .....................................................................................................

................................................................. Zip code:................................................

Principle Contact Phone No .......................................................................................

E-mail address: ........................................................................................................


____I would prefer to receive my newsletter/teaching program
        and other updates via email

____I am paying my membership in full  ____I will be making monthly payments


Mode of payment:

____enclosed is my check/money order for $ ..................

Please make your checks payable to: E-Vam Buddhist Institute


____credit card ____debit card (visa or master card only) $ ..................

Credit card number: .................................................................... Exp.date ___/___

Name on account: ...................................................................................................

Billing address: ........................................................................................................

.................................................................. Zip code:...............................................

Signature ................................................................................................................



Thank you for your support of E-Vam Buddhist Institute.


Please send the membership form to:

E-Vam Buddhist Institute
Membership
171 Water Street
Chatham, NY 12037