STATEMENT OF DUES FOR RENAL PATHOLOGY SOCIETY

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The yearly dues, payable by check, MasterCard or Visa, are as follows:

Regular member	US$ 75.00
Sustaining member	US$ 75.00 + 50.00
Special member (see WHO list)	US$ 25.00
Junior member	no fee
Emeritus status	no fee

To apply for emeritus status (65 years old or more) or to resign, complete the section at the bottom of this form and send to Dr. Liapis.

If you are paying by check, please make your check payable to The Renal Pathology Society and mail it to Dr. Liapis. Your canceled check will serve as your receipt. If you are paying by Visa or MasterCard, please fill out the information below and FAX or mail it to Dr. Liapis. We will send you a charge card receipt.

If you wish to contribute to the Pirani Travel Award, please select: $25, $50, $100, $200, Other

________ Visa________MasterCard

Credit Card #:__________________________________________________________________Exp. Date:_____/_____

Card Holder’s Signature:____________________________________________________________________________

Please verify that we have your correct preferred e-mail address, Name and Address, Telephone: FAX: E-mail

Return this form with your check to:

Dr. Helen Liapis, Secretary
Renal Pathology Society
Dept of Pathology & Immunology
Washington Univ. School of Medicine
660 South Euclid Ave.
Campus Box 8118
St. Louis, MO 63110

If you are paying by credit card you can FAX this form to

(314) 747-2040 or mail it.

Request for Emeritus Status

____ I am over 65 and want to apply for
emeritus status at this time
(No dues are required)

Resignation

____ I resign from the RPS.

_________________________________________________________________________
Signature of Member

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