Name  ____________________________________    Age _________

Mailing Address _________________________________________________

City ________________________________ State ____    Zip Code ___________

E-mail address _______________________________________________

Phone (______) _______-____________     Fax (______) _______-____________

I would like to become a member of AASP by making a tax-deductible contribution in the amount of $10 or more as indicated below.

(With a donation of $25 or more, you will receive a laser light key chain with AASP engraved on it.  With a donation of $50 or more, you will receive the key chain and either a long-sleeve t-shirt or sweat shirt with the AASP logo and Web site address printed on it.)

Amount of donation  [   ] $10     [   ] $25      [   ] $50     [   ] $100      [   ] other _______

Make membership check payable to AASP and send to the address listed at the bottom.

     [  ] I am donating $50 or more and would like a (check either t-shirt or sweat shirt):

            [  ]  long-sleeve t-shirt in (check size)    [  ] Medium     [  ]  Large      [  ]  Extra Large
                                                                       (Temporarily out of XXL & XXXL)

           [  ]  sweat shirt in (check size)                [  ]  Medium    [  ]  Large      [  ]  Extra Large
                                                                        [  ]  XXL         [  ]  XXXL

How did you hear about us?___________________________________________

AASP will not sell or share any name on our mailing list with outside sources.

AASP
PO Box 65756
Los Angeles, CA
90065
(800) 993-AASP