In-Region Membership Form - Association for Slavic_ East European

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In-Region Membership Form - Association for Slavic_ East European Powered By Docstoc
					                 ASSOCIATION FOR SLAVIC, EAST EUROPEAN, AND EURASIAN STUDIES
                                                203C BELLEFIELD HALL, UNIVERSITY OF PITTSBURGH  PITTSBURGH, PA 15260-6424
                                                      TEL: 412-648-9911  FAX: 412-648-9815  E-MAIL: ASEEES@PITT.EDU
                                       WWW.ASEEES.ORG  FACEBOOK.COM/SLAVIC.E.EUROPEAN.EURASIAN.STUDIES  TWITTER.COM/ASEEESTUDIES


                                2013 MEMBERSHIP FORM FOR PERMANENT
                              RESIDENTS OF EASTERN EUROPE AND EURASIA
 To become a new member of the ASEEES or to renew your membership, submit this form by email, mail or fax. We will mail you all 2013 issues of our publications if
 we receive your form or online membership submission on or before February 1, 2013; after that date, you must request shipment of issues already shipped.
 This form reflects reduced dues for low-income members permanently resident in Eastern Europe and Eurasia. These rates are available to individuals per-
 manently residing in one of the following countries: Albania, Armenia, Azerbaijan, Belarus, Bosnia-Herzegovina, Bulgaria, Croatia, Czech Republic, Estonia,
 Georgia, Hungary, Kazakhstan, Kosovo, Kyrgyz Republic, Latvia, Lithuania, Macedonia, Moldova, Montenegro, Poland, Romania, Russia, Serbia, Slovakia,
 Slovenia, Tajikistan, Turkmenistan, Ukraine, Uzbekistan. Scholars from the region temporarily resident elsewhere, and scholars from elsewhere temporarily resident in the
 region, are not eligible for this offer; please see www.aseees.org/ind.php for the regular membership form or to pay online.

 PERSONAL INFORMATION                                                                                                MEMBERSHIP DUES
                                                                                                                     Please select your annual income level to determine
 Title:                 ☐ Dr. ☐ Prof. ☐ Mr. ☐ Mrs. ☐ Ms. ☐ Other: _____________________________                      your dues amount.
 First Name:           ___________________________ Middle Name: ______________________________                       ☐ $125,000 and over ------------------------------------ $200
                                                                                                                     ☐ $100,000 to $124,999 -------------------------------- $180
 Last Name:            _____________________________________________________________________
                                                                                                                     ☐ $75,000 to $99,999 ----------------------------------- $155
 Institutional Affiliation:    ______________________________________________________________                        ☐ $60,000 to $74,999 ----------------------------------- $135
                                                                                                                     ☐ $50,000 to $59,999 ----------------------------------- $115
 E-mail Address:       _____________________________________________________________________
                                                                                                                     ☐ $40,000 to $49,999 ------------------------------------- $85
 Preferred Mailing Address:         ☐ Office     or    ☐ Home                                                        ☐ $30,000 to $39,999 ------------------------------------- $70
                                                                                                                     ☐ Under $30,000 ------------------------------------- $55 $30
 Office Address:       _____________________________________________________________________
                                                                                                                     ☐ Student ---------------------------------------------- $35 $15
                       _____________________________________________________________________                         ☐ Affiliate (receives NewsNet only) --------------- $45 $25

                       _____________________________________________________________________
                                                                                                                     ☐ Joint Member --------------------------------- add $40 $20
 Office Tel.:          ___________________________               Office Fax: ___________________________

 Home Address:         _____________________________________________________________________                         SHIPPING
                                                                                                                     Online access to Slavic Review will be provided by JSTOR.
                       _____________________________________________________________________                         Please select one option below:
                       _____________________________________________________________________                         ☐ I will read ASEEES publications online only. Please do not
                                                                                                                       send me printed copies of Slavic Review and NewsNet.
 Home Tel.:            ___________________________               Home Fax: ___________________________               ☐ I will read ASEEES publications in print only. I do not
                                                                                                                       wish to read publications online.
 ADD A JOINT MEMBER                                                                                                    ☐ I do not need access to JSTOR provided by ASEEES
                                                                                                                          and Slavic Review.
 Joint member shares your publications. Include joint member information below.
                                                                                                                     ☐ I would like both online access and print publications.
 Title:            ☐ Dr. ☐ Prof.    ☐ Mr.      ☐ Mrs. ☐ Ms.      ☐ Other: ____________________________
                                                                                                                     Additional postage is required if you do not select
 First Name:           ___________________________ Middle Name: ______________________________                       online only publications:
                                                                                                                     ☐ Postage outside North America -----------add $35
 Last Name:            _____________________________________________________________________
                                                                                                                     ☐ Affiliate postage outside the US ----------add $15
 Institutional Affiliation:    ______________________________________________________________

 E-mail Address:       _____________________________________________________________________
                                                                                                                     ENDOWMENT CONTRIBUTIONS
                                                                                                                     ASEEES is a 501(c)(3) non-profit organization; dues and optional
 Preferred Mailing Address:         ☐ Office     or    ☐ Home                                                        contributions may be tax deductible under certain circumstanc-
                                                                                                                     es—please consult your tax advisor. You may designate your
 Office Address:       _____________________________________________________________________                         contribution for the Kathryn Davis Fund, the Regional Scholar
                                                                                                                     Travel Grant Fund, and/or the unrestricted, board-designated
                       _____________________________________________________________________                         General Endowment. Donations are recognized in NewsNet.
 Office Tel.:          ___________________________               Office Fax: ___________________________
                                                                                                                     Kathryn Davis Fund:              $ _________________
 Home Address:         _____________________________________________________________________
                                                                                                                     Regional Scholar Travel
                       _____________________________________________________________________                         Grant Fund:                      $ __________________

 Home Tel.:            ___________________________               Home Fax: ___________________________
                                                                                                                     General Endowment:               $ _________________


PAYMENT INFORMATION                                                                                                                     TOTAL $ _______________
Note: All payments of membership dues and related postage fees are NON-refundable.

☐ Check or Money Order (Make payable to ASEEES in US dollars)

☐ Visa          ☐ MasterCard       ☐ American Express       Number: ______________________________________________________________ Exp.: ________ / __________


Name on Card:         _________________________________________________________ Cardholder Signature:          ______________________________________________


Billing Address:      ______________________________________________________________________________________________________________________________

     Please complete the second page of this form if you are a new member or if you would like to update your demographic information or directory preferences.
2013 MEMBERSHIP FORM, continued
 DEMOGRAPHIC INFORMATION
 This information is for statistical purposes only.
 Date of birth (M/D/Y):     ____________ / _________ / ___________

 Sex:                      ☐ Male          ☐ Female

 Employment Sector:        ☐ Academia      ☐ Business     ☐ Government         ☐ Military     ☐ Non-profit / NGO     ☐ Retired    ☐ Other ________________________

 EDUCATION
 The online Directory of Members will list only your most recent degree.
 Degree:                            Year Received:         Institution:                                                          Department:
  __________________________        ________________        ______________________________________________________               ________________________________
  __________________________        ________________        ______________________________________________________               ________________________________
  __________________________        ________________        ______________________________________________________               ________________________________

 DIRECTORY PREFERENCES
 The online Directory of Members will list your affiliation, e-mail address, office contact information (if available), position(s), specialization(s), countries of inter-
 est, period(s) of interest, and most recent degree. Please indicate below if you would like the directory to include your home contact information as well, or if
 you would like to be excluded from the directory entirely. The Directory of Members is only accessible to other members.
 ☐ Include my home contact information in the online Directory of Members.
 ☐ I do not want to be listed in the online Directory of Members at all.

 MAILING LIST OPT-OUT
 Members who do not opt-out may from time to time receive mailings about products and/or publications, including advertisements of new books or journals, or
 about services available to the community. Shared information with such groups will be restricted to mailing addresses, and will no t include any other details
 collected for your membership registration purposes.
 ☐ Do not include my mailing address on the list that ASEEES makes available to advertisers.

  REGION(S) OF INTEREST                      SPECIALIZATION(S)                              COUNTRIES OF INTEREST                   PROFICIENT LANGUAGE(S)
  ☐ Balkans                                    More specializations available online        ☐ Albania                                 More languages available online
  ☐ Baltic States                            ☐ Anthropology                                 ☐ Armenia                               ☐ Albanian
  ☐ Caucasus                                 ☐ Arts / Music                                 ☐ Austria                               ☐ Armenian
  ☐ Central Asia                             ☐ Business                                     ☐ Azerbaijan                            ☐ Azeri
  ☐ Central Europe                           ☐ Cinema                                       ☐ Belarus                               ☐ Belarusian
  ☐ Eastern Europe                           ☐ Communications                               ☐ Bosnia and Herzegovina                ☐ Bosnian
  ☐ Former Soviet Union                      ☐ Demography                                   ☐ Bulgaria                              ☐ Bulgarian
  ☐ Habsburg Empire                          ☐ Economics                                    ☐ Croatia                               ☐ Chinese Languages
  ☐ Ottoman Empire                           ☐ Education                                    ☐ Czech Republic                        ☐ Croatian
  ☐ Siberia                                  ☐ Env. / Ecological Studies                    ☐ Estonia                               ☐ Czech
                                             ☐ Ethnic Studies                               ☐ Finland                               ☐ Estonian
  POSITION(S)
                                             ☐ Folklore                                     ☐ Georgia                               ☐ Finnish
    More positions available online
                                             ☐ Geography                                    ☐ Germany                               ☐ French
  ☐ Administrator
                                             ☐ History                                      ☐ Greece                                ☐ Georgian
  ☐ Attorney
                                             ☐ Interdisciplinary                            ☐ Hungary                               ☐ German
  ☐ Clergy
                                             ☐ Int’l Relations / Foreign Policy             ☐ Kazakhstan                            ☐ Hungarian
  ☐ Consultant
                                             ☐ Journalism                                   ☐ Kyrgyzstan
  ☐ Curator                                                                                                                         ☐ Kazak
                                             ☐ Language                                     ☐ Latvia
  ☐ Editor / Publisher                                                                                                              ☐ Kyrgyz
                                             ☐ Law                                          ☐ Lithuania
  ☐ Instructor / Teacher
                                             ☐ Library / Information Services               ☐ Macedonia                             ☐ Latvian
  ☐ Lecturer
                                             ☐ Linguistics                                  ☐ Moldova                               ☐ Lithuanian
  ☐ Librarian / Info Specialist
                                             ☐ Literature                                   ☐ Mongolia                              ☐ Macedonian
  ☐ Post-Doctoral Fellow
                                             ☐ Military Affairs                             ☐ Montenegro
  ☐ Professor, Adjunct                                                                                                              ☐ Mongolian
                                             ☐ Philosophy                                   ☐ Poland
  ☐ Professor, Assistant                                                                                                            ☐ Old Church Slavonic
                                             ☐ Political Science                            ☐ Romania
  ☐ Professor, Associate                                                                                                            ☐ Polish
                                             ☐ Psychology / Psychiatry                      ☐ Russia
  ☐ Professor, Emeritus
                                             ☐ Public Health / Medicine                     ☐ Serbia                                ☐ Romanian
  ☐ Professor, Full
                                             ☐ Religion                                     ☐ Slovakia                              ☐ Russian
  ☐ Researcher
                                             ☐ Science / Technology                         ☐ Slovenia                              ☐ Serbian
  ☐ Retired
                                             ☐ Sociology                                    ☐ Tajikistan
  ☐ Student                                                                                                                         ☐ Slovak
                                             ☐Translation Studies                           ☐ Turkmenistan
  ☐ Translator                                                                                                                      ☐ Slovene
                                             ☐ Urban Studies                                ☐ Ukraine
  ☐ Writer                                                                                                                          ☐ Tajik
                                             ☐ Women’s Studies                              ☐ Uzbekistan
  ☐ Other ______________________
                                             ☐ Other ______________________                                                         ☐ Tatar
                                                                                                                                    ☐ Turkmen
                                                                                                                                    ☐ Uighur
                                                                                                                                    ☐ Ukrainian
                                                                                                                                    ☐ Uzbek
                                                                                                                                    ☐ Yiddish
                                                                                                                                    ☐ Other ______________________
 PERIOD(S) OF INTEREST
 ☐ pre-18th Century    ☐                 18th Century                     ☐   19th Century               ☐     20th Century                   ☐    21st Century

				
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