Date Submitted: ______________________________

Name : _______________________________________________________

Street Address1: _____________________________________________

Street Address2: _____________________________________________

City, State, ZIP: ____________________________________________

Email: ______________________________

Day/Night Phone: _________________ /_________________________

ANNUAL DUES are in 2 parts: $35 dues to ARSIRN and a $35 contribution to the Ayn Rand Center (ARC). Family membership is $60 to ARSIRN and $35 to ARC. {Note: ARSIRN is a Florida nonprofit corporation, but we have not yet been granted a 501c3 classification by the IRS. Until then, tax deductibility requires a separate check to the Ayn Rand Center.}

___ I am already an annual contributor to ARC/ARI. Enclosed are my ARSIRN dues for 2012.
___ I am not currently a contributor to ARC or ARI. Enclosed is my tax deductible check to the Ayn Rand Center for $_______ and my ARSIRN dues for 2012.
___ ASSOCIATE MEMBER (limited to 6 months): I am not ready to contribute to ARC but I would like to participate in ARSIRN activities as a member. Enclosed are my dues of $35.

STUDENT MEMBERSHIP: $15 + a contribution to ARI/ARC or volunteer to assist at ARSIRN functions as needed.

I attend (name of school): ________________________________________