USIIA Academic/
 Non-Profit Membership

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Organization:_____________________________________________

Address:_________________________________________________

City: ____________________ State:__________ Zip: ____________

Country: ____________ E-Mail:______________________________

Phone: ________________________ Fax:______________________

This membership entitles you to designate up to three USIIA members from your organization:

Member Name	Title	Phone	E-Mail

Complete all information and mail this document, along with a check or money order for dues, to Director of Member Services, US Internet Industry Association, 1800 Diagonal Road, Suite 600, Alexandria, VA 22314. The form may also be sent via fax (703-647-6009) or email.

Dues for Academic/Non-Profit Members are $500 per year. Dues are payable by check or money order and must accompany the membership application. This dues payment is not deductible as a charitable contribution. However, for most members this fee is deductible as a business expense. Up to twenty percent of member dues will be used for lobbying expenses on behalf of the members. Membership is not transferable or refundable. For further information contact USIIA at (703) 647-7440.