APPLICATION FOR MEMBERSHIP IN THE JEAN PIAGET SOCIETY Name: _________________________________________________ Address: ______________________________________________ _____________________________________________________ _____________________________________________________ City: _________________________________________________ State/Prov: _______________ ZIP/Postal Code: _________ Country: ______________________________________________ Institution: __________________________________________ _____________________________________________________ Electronic Mail: ______________________________________ Telephone: __________________ FAX: ___________________ By signing here, I consent to have my name, mailing and e-mail addresses listed on the Society's web site if I have provided the appropriate information. Signature: ___________________________________________ Fees for one year: 2006 Regular .............. $115 2006 Student/Postdoc ...... $50 (without journal) 2006 Student/Postdoc ...... $85 (with journal) Students must provide proof of current student status. INTERNATIONAL REDUCED RATE: Residents of the countries listed below are eligible for a 50% reduction in fees. If paying by credit card, check the appropriate fee category above and we will apply the 50% discount when processing your credit card payment. If paying by check or money order, check the appropriate fee category above and submit 50% of the stated fee. ___ I reside in one of the following countries: (based on World Bank categories for lending eligibility) Afghanistan, Albania, Algeria, Angola, Argentina, Armenia, Azerbaijan, Bangladesh, Belarus, Belize, Benin, Bhutan, Bolivia, Bosnia & Herzegovina, Botswana, Brazil, Bulgaria, Burkina Faso, Burundi, Cambodia, Cameroon, Cape Verde, Central African Republic, Chad, Chile, China, Colombia, Comoros, Congo, Costa Rica, Cote d'Ivoire, Croatia, Cuba, Czech Republic, Djibouti, Dominica, Dominican Republic, Ecuador, Egypt, El  Salvador, Equatorial Guinea, Eritrea, Estonia, Ethiopia, Fiji, Gabon, Gambia, Georgia, Ghana, Grenada, Guatemala, Guinea, Guinea-Bissau, Guyana, Haiti, Honduras, Hungary, India, Indonesia, Iran, Iraq, Jamaica, Jordan, Kazakhstan, Kenya, Kiribati, Kyrgyz Republic, Lao, Latvia, Lebanon, Lesotho, Liberia, Lithuania, Macedonia, Madagascar, Malawi, Malaysia, Maldives, Mali, Marshall Islands, Mauritania, Mauritius, Mexico, Micronesia, Moldova, Mongolia, Morocco, Mozambique, Myanmar, Namibia, Nepal, Nicaragua, Niger, Nigeria, Pakistan, Palau, Panama, Papua New Guinea, Paraguay, Peru, Philippines, Poland, Romania, Russia, Rwanda, Samoa, Senegal, Sierra Leone, Slovak Republic, Solomon Islands, Somalia, South Africa, Sri Lanka, St. Lucia, St. Vincent, Sudan, Suriname, Swaziland, Syria, Tajikistan, Tanzania, Thailand, Togo, Tonga, Trinidad and  Tobago, Tunisia, Turkey, Turkmenistan, Uganda, Ukraine, Uzbekistan, Vanuatu, Venezuela, Vietnam, Yemen, Zambia, Zimbabwe Tax-deductible contributions are welcomed. Checks must be in U.S. dollars payable to the Jean Piaget Society. Checks returned for any reason will incur a US$20 fee in addition to that charged by the banking system. Please indicate the amount(s) forwarded: Regular $___________ Student $___________ Institution $___________ Sustaining $___________ Patron $___________ Contribution $___________ TOTAL $___________ Membership Status (Check one): New ___ Renewal ___ If you choose to pay by credit card, all of the following information is required. Please type or print clearly. Type of Card (check one): VISA ___ MasterCard ___ Name (please print as it appears card): ____________________________________________________ Card number: _____________________ Expires: ________ Signature (required for credit card payment) ____________________________________________________ Please mail this form along with your payment to: Ashley Maynard Treasurer, Jean Piaget Society University of Hawaii Dept. of Psychology 2430 Campus Road Gartley #110 Honolulu, HI 96822 amaynard@hawaii.edu ------------------------------------------------------- ver. Oct-2005