NSS WikiNATIONAL SPACE SOCIETY Membership List Request Form Name and organization (if an NSS Chapter President, please list Chapter): ________________________________________________________________________ Date Requested: _____________________________ Date Needed: _____________________________ NSS Contact: _____________________________ Description of Event or Activity: _____________________________ State, Region or Zip Code Ranges (i.e., Texas, Springfield, 22202-22314): ________________________________________________________________________ ________________________________________________________________________ Check List Format (All sorted by zip code): Pressure-sensitive labels _______ Disk (sent on 3 ½” IBM-formatted floppy) _______ E-mail attachment _______ Ship to: ____________________________________________________________ (Please allow 2-3 weeks for delivery) I understand that this membership list is to be used solely for the event listed on this Request Form. Signed: _____________________________ Date: ________________________ Pricing: NSS Chapter Presidents: Complimentary All others: .15/name + $25.00 setup cost for more than 1,000 labels Please contact NSS Headquarters if you have any questions: National Space Society 1620 I (Eye) Street NW, Suite 615, Washington, DC 20006 Tel: (202) 429-1600 -- FAX: (202) 463-8497 -- E-mail: nsshq@nss.org