The American Society of São Paulo

Fill out our on-line form to become a member:

Your information
Last Name (*):		Name (*):
Nationality:		Year arrived in Brazil:
Date of Birth:		Home State:
Home Address (*):		State (*):
CEP/ZIP:		City (*):
Fone (*):		Cellphone (*):
E-mail (*):		Fax:

Business
Company:
Address:		State:
CEP/ZIP:		City:
Fone:		Cellphone:
E-mail:		Fax:

Spouse
Name:
Nationality:		Year arrived in Brazil:
Date of Birth:		Home State:
E-mail:		Cellphone:

Children(under 21)
Name:		Date of Birth:

Which category would you like to join?
HELPING HANDS - R$700 (50% goes to an AmSoc-sponsored charity) SUPPORTING MEMBER - Single Membership R$200 SUPPORTING MEMBER - Family Membership R$250 PATRON MEMBER - Single Patron Membership R$ 250 PATRON MEMBER - Family Patron Membership R$350

Permission to print in the yearbook?		Yes	No

Address for correpondence:		Home	Work

How did you find out about the American Society?
Newcomer Friend Name: Internet Other

Did an Amsoc member refer you to our organization?
No	Yes	Name:

Phone: 55 11 5182-2074