Ecuadorean American Association

Application for Membership

Date:

Type of Membership:

Sustaining Membership $ 2,000.00 per annum
Resident Corporate Membership, representing a corporation or partnership with offices in the United States $ 500.00 per annum
Resident Individual Membership, residing or having offices within the United States $200.00 per annum
Non-resident membership, residing or having offices outside the United States $110.00 per annum
Fulltime Student $85.00 per annum

Name of Applicant:
Title:
Name of Company:
Address:
City:
State:
ZipCode:
Country:
Telephone:
Fax number:
E-Mail:
WebPage

PAYMENT:

By check

Amount

By credit card

American Express

Mastercard

Visa

Please provide the following account information:

Name

Card #

Exp. Date

Applicable for Supporting and Corporate Members: Please provide a list of colleagues (including their address and phone/fax/E-mail) who would like to receive nvitations to events.

30 Vesey Street, Suite 506, New York, NY 10007
Tel: (212)233-7776 Fax: (212)233-7779
E-mail: andean@nyct.net

Founded in 1932