AMNESTY INTERNATIONAL MEMBERSHIP To join Amnesty International USA by mail, please print this form, complete all the information and mail to the address provided below. ________________________________________________________________ Amnesty International works impartially to free prisoners of conscience (men women, and children imprisoned solely for their beliefs, race, or ethnic origin who have neither used nor advocated violence); for fair and prompt trials for all political prisoners, to abolish the death penalty and torture in all cases, and an end to extra-judicial executions and "disappearances". ________________________________________________________________ ___ I would like to make a donation to Amnesty International. ___ Please renew my membership in Amnesty International. ___ I would like to join Amnesty International. Enclosed are my dues: ___ Individual $25 a year ___ Senior Citizen/Limited Income $15 a year ___ Student $15 a year ___ I understand that Amnesty International depends upon the generosity of its members. Therefore, I would like to make an additional contribution. For membership dues and a contribution combined I am giving: ___ $50 ___ $75 ___ $100 ___ $250 ___ other ___ I would like to give a gift of Amnesty International membership. If giving a gift membership, please include the name, address, phone number and email address of the gift recipient. Contributions to Amnesty International USA are tax-deductible. In addition to joining Amnesty International, I'd like to learn more about: (Please check as many as apply) ___ Local Groups ___ Student Groups ___ Freedom Writers Network ___ Urgent Action Network ___ Raise the Roof! Legislative Network ___ Women's Human Rights / Women's Action Council ___ Health Professionals ___ Legal Support Network ___ Children's Rights Network ___ Human Rights Educator's Network ___ Outfront Program for Lesbian and Gay Human Rights ___ Publications/Merchandise Catalog ___ Partners of Conscience (monthly giving) Name __________________________________________________________ Address _______________________________________________________ _______________________________________________________________ City _____________________________ State __________ Zip _______ Phone (________)_______________________________________________ E-mail ________________________________________________________ I want to give by: _____ Check (made payable to Amnesty International USA) _____ MasterCard _____ Visa _____ American Express _____ Discover Card Card # ________________________________________________________ Expiration Date: _____/_____ Signature _____________________________________________________ Please send this form: Amnesty International USA attn: Member Services Department 5 Penn Plaza, 14th Floor New York, NY 10001 or call 1-800-AMNESTY W66CRG _______________________________________________________________