Contributions Form
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1S
E
G
, I
.
OCIETY OF
CONOMIC
EOLOGISTS
NC
S
E
G
F
, I
.
OCIETY OF
CONOMIC
EOLOGISTS
OUNDATION
NC
7811 Shaffer Parkway • Littleton, CO 80127-3732 USA • Tel: +1.720.981.7882 • Fax: +1.720.981.7874 • E-mail:
Contributions
(This form may also be used by Companies, Institutions and Non-Members)
Member Name ________________________________________________ ________________________________ ____________ Member No. ______________
Last Name
First Name
Middle Initial
Company / Institution ____________________________________________________________________________________________________________________
Mailing Address
Home or
Business ________________________________________________________________________________________________
City ________________________________________ State/Province ________________________ Postal Code________________ Country____________________
Phone ______________________________________________________________ Fax_______________________________________________________________
Email _________________________________________________________________________________________________________________________________
CONTRIBUTIONS* (Please indicate your selection)
SEG General Fund
$_______________
Foundation General Fund
$_______________
Discovery Fund
$_______________
Hugo T. Dummett Fund
$_______________
Alberto Terrones L. Fund
$_______________
Timothy Nutt Fund
$_______________
Student Field Trip Fund
$_______________
Student Fellowship Fund
$_______________
Hugh E. McKinstry Fund
$_______________
Hickok-Radford Fund
$_______________
Canada Foundation
$_______________
TOTAL
$ ____________________
PAYMENT (US dollars only)
VISA
MASTERCARD
AMEX
DISCOVER
CHECK (US Funds – Payable to S.E.G.)
US $ _____________
/
Card No. _______________________________________________________________ Card Security Code ____________________ Expiry Date_____________
(3–4 digit code on back/front of credit card)
Print Name as it appears on card_________________________________________________________________________________________________________
Signature of Applicant _____________________________________________________________________________ Date_______________________________
Please Mail or Fax to: +1.720.981.7874
Society of Economic Geologists, 7811 Shaffer Parkway, Littleton, CO 80127-3732, USA
*CONTRIBUTIONS: Income from invested contributions is used to support professional activities of both organizations. The SEG and
the SEG Foundation are tax-exempt 501(c)(3) corporations under U.S. IRS code. The SEG Canada Foundation is a charitable organiza-
tion registered with the Canada Customs and Revenue Agency.
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