Membership Application Form
First time membership or renewal? (check one)
___ New membership ___ Renewal
Yearly Membership Levels (check level)
___$100 NSS Member
___$250 NSS Charter Member
(limited time 2007 and 2008 only)
___$50 (optional) Members Directory listing with weblink
…(fill out form below)
___$500 Business Member
FREE: Business Members receive a complementary directory listing
…(fill out form below)
Donations: support NSS work in the world
$_______ (Amount)...thank you!
Member Directory Listing Form:
Name: __________________________________
(100 word description max)_____________________________________
_____________________________________________________________
_____________________________________________________________
_____________________________________________________________
_____________________________________________________________
_____________________________________________________________
_____________________________________________________________
Contact: ___________________________________
Website: ___________________________________
Credit Card Information
Card Type ___ Visa ___ Mastercard
Cardholder Name ________________________________________
Expiration Date ___/___
Card Number ___________________________________________
NOTE: You may also pay by check or cash.
Please fill out name/address, print this form and mail the form along with the payment to:
Northland Shamanic Society
ATTN: Connie Grauds
4815 Minneapolis Avenue
Minnetrista, MN 55364
Name: ________________________________________________________________
Street: ________________________________________________________________
City: ________________________________________ State: ____ Zip _________
Phone: ______________________ Email : __________________________________