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Please complete this form, review your information, then print (File > Print) and mail this form with your $20 1-year membership fee to the address below (you may also opt to pay for multiple years).
Please be sure your e-mail address is correct and typed or printed clearly, as you will receive your membership information via e-mail.
| Full Name | |
| Title/Affiliation | |
| Street Address | |
| City | |
| State | (U.S Applicants Only) |
| Non-U.S. Region/Province | (International Applicants Only) |
| Zip Code/Postal Code | |
| Country | |
| Phone | |
| Areas of interest | |
| Website | |
|
It is recommended that you provide a "permanent" e-mail address (such as a Hotmail, Yahoo, or a home account) rather than one that you may change or discontinue to use (such as a work or school e-mail account) |
|
| Choose Your Password |
(Letters and numbers only, minimum of 5 characters) |
| How you found the Society | |
| Comments |
Make check or money order payable to "Julian Jaynes Society."
Mail this form to:
Marcel Kuijsten, Executive Director
Julian Jaynes Society
2243 Cassatt Drive
Henderson, NV 89074-5065