Membership Application

I would like to become a member ($45) of The Silvan S. Tomkins
Institute. (Overseas, $55.)

Please accept this donation of ($25) ($50) ($100) ($_____)  to
help the Institute.

I enclose a donation of $_______ for the Michael Franz Basch
Memorial Lectureship.


Enclosed is my check in the amount of $_______. (US dollars only)

I wish to pay by credit card (VISA or MASTERCARD only)

  Card Number:_______________________  Expiration Date:_______

  Signature:_____________________________ (absolutely required)


Name:_________________________________________________________

Address:______________________________________________________

City, State, Zip:_____________________________________________

Phone (office):_________________  Phone (home):_______________

Internet Address:_____________________________________________


Please make checks payable to the Tomkins Institute and return
to:

    Silvan S. Tomkins Institute
    Suite 2403
    255 South 17th Street
    Philadelphia, PA   19103-6224