*Name, including desired title (Dr., Mrs., CEM, RN, etc.)

*Email

Organization (if any)

*Mailing Address (Street or P.O. Box)

Additional Line for Address

*City, State, Postal Code (ZIP), and Country if not USA, Mexico or Canada                    

Telephone (Optional)

Radio Call Sign (Optional)

*Membership Classification
Select One Executive Management $75 Professional / Technical /Academic $50 Unpaid Volunteer $25 Student $25 Retired $25 Lifetime Individual $450 Nonprofit Organization $75 Gov't Agency $95 Business Member $125 Corporate Sponsor $500 Annual Dues Rate in U.S. Dollars (USD)

Enter dollar amount of any additional Tax-Deductible donation you wish to make

*Type of Card
Select OneVisaMasterCard

*Card Number (Please include spaces)

*Expires
(MM/YY)

Name of Card Holder, if different from applicant

  If application is mailed, please use the above block for cardholder's signature

"By submitting this form I certify that I am authorized to bill charges to this account and that I will be responsible for proper payment. My billing statement will indicate "DERA Disaster Resource Center" as the merchant for this transaction. I will notify DERA promptly in writing of any billing errors. I will give DERA a reasonable opportunity to resolve any complaints. DERA may be contacted by email at dera@disasters.org or by postal mail at P.O. Box 797, Longmont, CO 80502 USA."

DERA is a US IRS 501(c)(3) nonprofit organization   -    Federal Tax ID Number (EIN): 39-1777651