InMATYC Membership Form

Annual Membership Dues: $20.00

Make checks payable to InMATYC

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Mail to:	Hank Hernandez, Department of Mathematics Indiana University - Purdue University Indianapolis 402 North Blackford Street Indianapolis, IN 46202 (317) 278-9644
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Print this form and complete it to become a member or to renew your membership in InMATYC:

Name: ________________________________________________________________________

School: _______________________________________________________________________

School Address: ________________________________________________________________

City: ______________________________ State: __________________ ZIP: ______________

Phone: ___________________________________ FAX: _______________________________

E-mail: _______________________________________________________________________

Web Site (if you have one): _______________________________________________________

Please indicate your home address if you prefer to receive mailings at home.

Home Address: _________________________________________________________________

City: ______________________________ State: __________________ ZIP: ______________

This form can be printed off the InMATYC Web Site by clicking the Membership Form (DOCX)