MIT CLUB OF NORTHERN CALIFORNIA

Membership Form – August 1, 2007 through July 31, 2008

Name: __________________________    Course: _______   Class: _______

Street Address: _________________________________________________

                            _________________________________________________

City/State/Zip: __________________________________________________

Phone:  __________________    e-mail (required)*: ____________________

* Note:  you are providing this e-mail address so that the club can provide you notices regarding official club business.

Address shown is:     Home ____    Business ____

Please select a membership category:

[   ]       $30     Regular Membership

[   ]       $50     Sustaining Membership¹

[   ]       $100   Patron Membership¹

[   ]       Free    Class of 2007 or class of ’57 and earlier

[   ]       Free    Currently Enrolled Student

Membership Dues                $_____________

Scholarship Donation           $_____________

Total enclosed                       $_____________

1.  Sustaining and Patron Members enjoy the same benefits as Regular Members, however, they make a greater 

financial contribution to the club.

Please make checks payable to MIT Club of Northern California and return with

form to:

MIT Club of Northern California
470 Columbus Avenue
Suite 206
San Francisco, CA 94133-3930
ATTN: Michael Sarfatti

For on-line registration please visit our website:  http://www.mitcnc.org/Join.htm