Name_______________________________________________________
Position__________________________
Email__________________________
Employer_____________________
Location_________________________
Business
Address_______________________________________________
City_______________
Zip_____
Business
Phone________________ Business Fax______________________
Soc.Sec.#________________
(
) I hereby authorize a payroll deduction of $19.00 per month from my
salary to be paid to NASA for the purpose of professional dues. I authorize
this deduction immediately and will continue until the Executive Director
is notified in writing of my intention to terminate membership.
Signature:________________________________