Membership Form Please send to: Dr. Charles E. Ribak Secretary/Treasurer of Cajal Club Department of Anatomy & Neurobiology University of California at Irvine School of Medicine Irvine, CA 92697-1275 USA Please complete and return with your Membership Fee. NAME ADDRESS CITY/STATE/ZIP EMAIL FAX MEMBERS RESIDING OUTSIDE USA SHOULD MAKE PAYMENT IN US DOLLARS ONLY. We cannot accept credit card payments. MEMBERSHIP FEE (Please check one or more) ___ Active Member ..............$30.00 ___ Student/Postdoc Member ....$10.00 ___ Retired Member .............$0 Please make checks payable to: CAJAL CLUB ANNUAL DUES FOR 2009-2010 Please complete and return with 2009-2010 Cajal Club annual membership dues. NAME ADDRESS CITY/STATE/ZIP EMAIL FAX MEMBERS RESIDING OUTSIDE USA SHOULD MAKE PAYMENT IN U.S. DOLLARS DRAWN ON A U.S. BANK. We cannot accept credit cards for Cajal Club dues payments MEMBERSHIP DUES (PLEASE CHECK ONE) ___ Active Member ………………………….$30.00 ___ Student/Postdoc Member…………….$10.00 ___ Retired Member……………………..…$0 TAX EXEMPT DONATIONS ___ Donations for support of student activities (i.e., travel grants, poster prizes, etc.) Please indicate whether you want a pin (they are in limited supply). Please make checks payable to: Cajal Club Please return completed form with your check to: Charles E. Ribak, Ph.D. Cajal Club, Office of the Secretary/Treasurer Department of Anatomy & Neurobiology University of California at Irvine Irvine, CA 92697-1275