Membership Application

<body topmargin=0 leftmargin=0 marginheight=0 marginwidth=0> <table cellpadding=0 cellspacing=0 border=0><tr> <td valign="top" colspan=2 height=90 BGCOLOR="#006699" TEXT="#080000" bgproperties="fixed" background="4f6005a2erlcgo.jpg"> <div> <B> </B><FONT SIZE="1" COLOR="#000000" FACE="Arial" > <OBJECT classid="clsid:D27CDB6E-AE6D-11cf-96B8-444553540000" codebase="http://download.macromedia.com/pub/shockwave/cabs/ flash/swflash.cab#version=5,0,0,0" width="569" height="78"> <PARAM name="movie" value="avicultureflashtop.swf"> <PARAM NAME="wmode" VALUE="transparent"> <PARAM name="quality" value="high"> <PARAM name="menu" value="true"> <EMBED src="avicultureflashtop.swf" WMODE="transparant"quality="high" menu="true" pluginspage="http://www.macromedia.com/shockwave/download/index.cgi?P1_Prod_Version=ShockwaveFlash" type="application/x-shockwave-flash" width="569" height="78"> </EMBED> </OBJECT>  </FONT></div> <div> </div> </td> </tr><tr> <td valign="top" width=210 BGCOLOR="#FFCC66" TEXT="#080000" background="4ced2b03.jpg"> <div>  <img src="HTMLobj-297/aniGif.gif" border="0" align="bottom" width="41" height="30">  </div> <bR> <bR> <div> <B> <META content="text/html; charset=windows-1252" http-equiv=Content-Type> <META content=revealTrans(Duration=2.0,Transition=23) http-equiv=Page-Enter> <META content=revealTrans(Duration=2.0,Transition=23) http-equiv=Page-Exit>  </B></div> <div> <A HREF="id104.htm" TARGET="_top" TITLE="_"><U><B>--Type Title Here--</B></U></A></div> <bR> <bR> <div> <A HREF="id96.htm" TARGET="_top" TITLE="ETHICAL RESPONSIBILITY"><U><B>ETHICAL RESPONSIBILITY</B></U></A></div> <bR> <div> <A HREF="aviculture_development___education_foundation__inc_.htm" TARGET="_top" TITLE="_"><U><B>--Type Title Here--</B></U></A></div> <bR> <div> <A HREF="id46.htm" TARGET="_top" TITLE="aviculture.org/Birds/muse"><U><B>aviculture.org/Birds/muse</B></U></A></div> <bR> <div> <A HREF="id45.htm" TARGET="_top" TITLE="MEMBERS SPONSORS"><U><B>MEMBERS SPONSORS</B></U></A></div> <bR> <div> <A HREF="id83.htm" TARGET="_top" TITLE="AVICULTURE AND AVICULTURAL MEDICAL PRACT"><U><B>AVICULTURE AND AVICULTURAL MEDICAL PRACTICE</B></U></A></div> <bR> <div> <A HREF="id84.htm" TARGET="_top" TITLE="THE PATHOGEN VS. THE PATHOGENESIS:"><U><B>THE PATHOGEN VS. THE PATHOGENESIS:</B></U></A></div> <bR> <div> <A HREF="contact.htm" TARGET="_top" TITLE="CONTACT"><U><B>CONTACT</B></U></A></div> <bR> <div> <A HREF="id104.htm" TARGET="_top" TITLE="_"><U><B>--Type Title Here--</B></U></A></div> <bR> <bR> <bR> <bR> </td> <td valign="top" height=390 BGCOLOR="#BBBBBB" TEXT="#080000"> <div> <B>Membership Application</B></div> <div> <B> <div><FONT SIZE="3" COLOR="#000000" FACE="Arial,Helvetica,sans-serif"><B>To print the application, click the </B><FONT COLOR="#0000FF"><B>Print Button</B></FONT><B> in your browser window.</B> </FONT></div> <div><FONT SIZE="3" COLOR="#000000" FACE="Arial,Helvetica,sans-serif"> <FORM METHOD=post ACTION="http://aviculture.org/cgi-sys/FormMail.cgi"> <input type=hidden name="recipient" value="CEO@aviculture.org"> <input type=hidden name="recipient" value="afqueen@gate.net"> <input type=hidden name="subject" value="Membership Application"> <input type=hidden name="required" value="name,email,state,phone"> <input type=hidden name="env_report" value="REMOTE_HOST,HTTP_USER_AGENT"> <input type=hidden name="redirect" value="http://www.aviculture.org/id89.htm"> Name of Organzation: <INPUT TYPE="text"Name="realname" size=30 MAX=30> </script> </tr> </table> </div> <div align="left"> <tab> </ </div> <p> <br> </p> </td><td valign="top" width="24"><font size="4"><font color="#666699"></td><td valign="top"> <p><br>Background information, is most helpful for the integrity of the Foundation and its purpose, so please accomodate this request to make your application process quickly</p> <p>If you'd like more information about the Foundation please contact <a href="mailto:lucielady@aol.com">lucielady@aol.com</a></p> <input TYPE="hidden" NAME="Foundation" VALUE="0"> <p>Please provide history regarding your breeding birds.</p> <div align="center"> <center> <table border="0" cellpadding="3" cellspacing="0" width="90%"> <tr> <td>Your Name</td> <td><INPUT name="Name" value="" size="35"><BR> </tr> <tr> <td>Address 1</td> <td><input type="text" name="Address_1" size="35"></td> </tr> <tr> <td>Address 2</td> <td><input type="text" name="Address_2" size="35"></td> </tr> </table> </center> </div> <div align="center"> <center> <table border="0" cellpadding="0" cellspacing="0" width="90%"> <tr> <td>City</td> <td><input type="text" name="City" size="14"></td> <td>State</td> <td><input type="text" name="State" size="5"></td> <td>Zip</td> <td><input type="text" name="Zip" size="9"></td> </tr> </table> </center> </div> <p>Your home page:</B> <INPUT type=text name="hpage" value="http://" size=40> <br> </p> <div align="center"> <center> <table border="0" cellpadding="0" cellspacing="0" width="90%"> <tr> <td>Email</td> <td><input type="text" name="Email" size="20"></td> </tr> <tr> <td>Phone</td> <td><input type="text" name="Phone" size="20"></td> </tr> <tr> <td>Foundation member participation:<br> <font size="2"><font color="#666699"> Please hold CTRL Key to make multiple selections.</font><br> Veterinarian Sponsor Inquiry, choose other.</font></td> <td><select size="6"name="Membership" multiple> <option>Study Reference Guide,</option> <option>Advisory Board,</option> <option>Volunteer,</option> <option>Ad Hoc Advisory Board,</option> <option>Educational benefactor</option> <option>Other</option> </select></td> </tr> <p><tr> <td><font size="4"><font color="#000030"><br>Aviculture Microbiology Foundation, Inc.<br> <br> Thank you,<br> Board of Directors <br> <br>1. How did you learn about Aviculture Microbiology Foundation,Inc.?<br><input type="text" 1.="1." size=30 MAX=30><br> <br>2. Were you referred to this Foundation by someone?<br><input type="radio" name="referred" value="yes">Yes<br><input type="radio" name="other" value="no">No<br> <br>3. If so, Who?<br><input type="text" 1.="1." size=30 MAX=30><br> <br>4. How long have you been active with birds?<br><input type="text" 4.="4." size=10 MAX=10><br> <br>5. Are you a breeder of birds?<br><input type="radio" name="breeder" value="yes">Yes<br><input type="radio" name="breeder" value="no">No<br> a. Pet Owner?<br><input type="radio" name="petowner" value="yes">Yes<br><input type="radio" name="petowner" value="no">No<br> b. Pet Shop Owner?<br><input type="radio" name="petshop" value="yes">Yes<br><input type="radio" name="petshop" value="no">No<br> c. Rescue Birds Unit?<br><input type="radio" name="rescue" value="yes">Yes<br><input type="radio" name="rescue" value="no">No<br> <br>6. Do you own 10 or less birds?<br><input type="radio" name="10less" value="yes">Yes<br><input type="radio" name="10less" value="no">No<br> a. Over ten birds?<br><input type="radio" name="10over" value="yes">Yes<br><input type="radio" name="10over" value="no">No<br> <br>7. Your reason for wanting to join this Foundation?<br><input type="text" 7.="7." size=30 MAX=30><br> <br>8. What do you hope to learn and/or accomplish by joining Aviculture Microbiology Foundation,Inc.?<br><input type="text" 8.="8." size=30 MAX=30><br> <br>9. If accepted, what will your first contribution be to the Foundation as a member?<br><input type="text" 9.="9." size=30 MAX=30><br> <tr> <td>Please note species of birds under your care now, or species you have had experience with:<br> <font size="2"><font color="#666699"> Please hold CTRL Key to make multiple selections.</font><br> If not listed choose other.</font></td> <td><select size="5"name="Species" multiple> <option>African,</option> <option>Macaws,</option> <option>Cockatoos,</option> <option>Soft Bill,</option> <option>Other</option> <option>Other</option> </select></td> </tr> <tr> <td>Comments.</td> <td><textarea rows="7" name="General_Comments" cols="27"></textarea></td> </tr> </table> </center> </div> <p align="center"><input name="order" type="submit" value="Submit Form"> <input name="reset" type="reset" value="Clear Form"> <input type="button" value="Pam Suite" onClick="parent.location='mailto:lucielady@aol.com'" name="button"><br><br>  </FONT></div> <bR> <bR> <div> <div ALIGN="LEFT"> <TABLE BORDER="2" CELLPADDING="1" CELLSPACING="1" WIDTH="580" BORDERCOLORLIGHT="#C0C0C0" BORDERCOLORDARK="#808080" FRAME="BOX" RULES="ALL" HSPACE="0" VSPACE="0" > <tR> <tD VALIGN=CENTER BGCOLOR=#FFFFFF HEIGHT= 50 WIDTH="95"><div><FONT SIZE="3" COLOR="#0000FF" FACE="Arial,Helvetica,sans-serif"><B>Name: </B><FONT SIZE= 1 >(please print clearly)</FONT></FONT></div> </tD> <tD VALIGN=CENTER COLSPAN=4 BGCOLOR=#FFFFFF WIDTH="464"><IMG BORDER="0" SRC="1x1.gif" HEIGHT="50" ALIGN="bottom" WIDTH="464" HSPACE="0" VSPACE="0"></tD> </tR> <tR> <tD VALIGN=CENTER BGCOLOR=#FFFFFF HEIGHT= 20 ><NOBR><div><FONT SIZE="3" COLOR="#0000FF" FACE="Arial,Helvetica,sans-serif"><B>Address:</B></FONT></div> </NOBR></tD> <tD VALIGN=CENTER COLSPAN=4 BGCOLOR=#FFFFFF WIDTH="464"><IMG BORDER="0" SRC="1x1.gif" HEIGHT="20" ALIGN="bottom" WIDTH="464" HSPACE="0" VSPACE="0"></tD> </tR> <tR> <tD VALIGN=CENTER BGCOLOR=#FFFFFF HEIGHT= 20 WIDTH="95"><div><FONT SIZE="3" COLOR="#0000FF" FACE="Arial,Helvetica,sans-serif"><B>City:</B></FONT></div> </tD> <tD VALIGN=CENTER COLSPAN=4 BGCOLOR=#FFFFFF WIDTH="464"><IMG BORDER="0" SRC="1x1.gif" HEIGHT="20" ALIGN="bottom" WIDTH="464" HSPACE="0" VSPACE="0"></tD> </tR> <tR> <tD VALIGN=CENTER BGCOLOR=#FFFFFF HEIGHT= 20 WIDTH="95"><div><FONT SIZE="3" COLOR="#0000FF" FACE="Arial,Helvetica,sans-serif"><B>State:</B></FONT></div> </tD> <tD VALIGN=CENTER COLSPAN=4 BGCOLOR=#FFFFFF WIDTH="464"><IMG BORDER="0" SRC="1x1.gif" HEIGHT="20" ALIGN="bottom" WIDTH="464" HSPACE="0" VSPACE="0"></tD> </tR> <tR> <tD VALIGN=CENTER BGCOLOR=#FFFFFF HEIGHT= 20 WIDTH="95"><div><FONT SIZE="3" COLOR="#0000FF" FACE="Arial,Helvetica,sans-serif"><B>Zip:</B></FONT></div> </tD> <tD VALIGN=CENTER COLSPAN=4 BGCOLOR=#FFFFFF WIDTH="464"><IMG BORDER="0" SRC="1x1.gif" HEIGHT="20" ALIGN="bottom" WIDTH="464" HSPACE="0" VSPACE="0"></tD> </tR> <tR> <tD VALIGN=CENTER BGCOLOR=#FFFFFF HEIGHT= 23 ><NOBR><div><FONT SIZE="3" COLOR="#0000FF" FACE="Arial,Helvetica,sans-serif"><B>AC/Phone:</B></FONT></div> </NOBR></tD> <tD VALIGN=CENTER COLSPAN=4 BGCOLOR=#FFFFFF WIDTH="464"><div><FONT SIZE="4" COLOR="#0000FF" FACE="Arial,Helvetica,sans-serif">( )</FONT></div> </tD> </tR> <tR> <tD VALIGN=CENTER BGCOLOR=#FFFFFF HEIGHT= 20 WIDTH="95"><div><FONT SIZE="3" COLOR="#0000FF" FACE="Arial,Helvetica,sans-serif"><B>Email:</B></FONT></div> </tD> <tD VALIGN=CENTER COLSPAN=4 BGCOLOR=#FFFFFF WIDTH="464"><IMG BORDER="0" SRC="1x1.gif" HEIGHT="20" ALIGN="bottom" WIDTH="464" HSPACE="0" VSPACE="0"></tD> </tR> <tR> <tD VALIGN=TOP BGCOLOR=#FFFFFF HEIGHT= 112 WIDTH="95"><div><FONT SIZE="3" COLOR="#0000FF" FACE="Arial,Helvetica,sans-serif"><B>Aviculture History:</B></FONT></div> <bR> </tD> <tD VALIGN=CENTER COLSPAN=4 BGCOLOR=#FFFFFF WIDTH="464"><bR> <bR> <bR> <bR> <bR> <bR> </tD> </tR> <tR> <tD VALIGN=TOP ROWSPAN=3 BGCOLOR=#FFFFFF HEIGHT= 38 ><NOBR><div><FONT SIZE="3" COLOR="#0000FF" FACE="Arial,Helvetica,sans-serif"><B>Membership</B></FONT></div> </NOBR></tD> <tD VALIGN=CENTER COLSPAN=2 BGCOLOR=#FFFFFF><NOBR><div><FONT SIZE="3" COLOR="#0000FF" FACE="Arial,Helvetica,sans-serif">Please only check one (New or Renewal)</FONT></div> </NOBR></tD> <tD VALIGN=CENTER COLSPAN=2 BGCOLOR=#FFFFFF WIDTH="120"><div><FONT SIZE="3" COLOR="#0000FF" FACE="Arial,Helvetica,sans-serif">Please only check one</FONT></div> </tD> </tR> <tR> <tD VALIGN=CENTER BGCOLOR=#FFFFFF WIDTH="169"><div><FONT SIZE="3" COLOR="#0000FF" FACE="Arial,Helvetica,sans-serif"><B>New $50.00</B></FONT></div> </tD> <tD VALIGN=CENTER BGCOLOR=#FFFFFF WIDTH="169"><div><FONT SIZE="3" COLOR="#0000FF" FACE="Arial,Helvetica,sans-serif"><B>Renewal $50.00</B></FONT></div> </tD> <tD VALIGN=CENTER BGCOLOR=#FFFFFF WIDTH="0"><IMG BORDER="0" SRC="1x1.gif" HEIGHT="20" ALIGN="bottom" WIDTH="0" HSPACE="0" VSPACE="0"></tD> <tD VALIGN=CENTER BGCOLOR=#FFFFFF><NOBR><div><FONT SIZE="3" COLOR="#0000FF" FACE="Arial,Helvetica,sans-serif"><B>Single - $50.00</B></FONT></div> </NOBR></tD> </tR> <tR> <tD VALIGN=CENTER BGCOLOR=#FFFFFF WIDTH="169"><IMG BORDER="0" SRC="1x1.gif" HEIGHT="19" ALIGN="bottom" WIDTH="169" HSPACE="0" VSPACE="0"></tD> <tD VALIGN=CENTER BGCOLOR=#FFFFFF WIDTH="169"><IMG BORDER="0" SRC="1x1.gif" HEIGHT="19" ALIGN="bottom" WIDTH="169" HSPACE="0" VSPACE="0"></tD> <tD VALIGN=CENTER BGCOLOR=#FFFFFF WIDTH="0"><IMG BORDER="0" SRC="1x1.gif" HEIGHT="19" ALIGN="bottom" WIDTH="0" HSPACE="0" VSPACE="0"></tD> <tD VALIGN=CENTER BGCOLOR=#FFFFFF WIDTH="117"><IMG BORDER="0" SRC="1x1.gif" HEIGHT="19" ALIGN="bottom" WIDTH="117" HSPACE="0" VSPACE="0"></tD> </tR> </TABLE></div> </div> <div><IMG BORDER="0" SRC="1x1.gif" HEIGHT="1" ALIGN="bottom" WIDTH="1" HSPACE="0" VSPACE="0" ></div> <bR> <bR> <bR> <bR> <div> <div ALIGN="LEFT"> <TABLE BORDER="2" CELLPADDING="1" CELLSPACING="1" WIDTH="410" BORDERCOLORLIGHT="#0000FF" BORDERCOLORDARK="#0000BF" FRAME="BOX" RULES="ALL" HSPACE="0" VSPACE="0" > <tR> <tD VALIGN=CENTER BGCOLOR=#FFFFFF HEIGHT= 19 ><NOBR><div><FONT SIZE="3" COLOR="#000000" FACE="Arial,Helvetica,sans-serif">Aviculture Microbiology Foundation,Inc.</FONT></div> </NOBR></tD> </tR> <tR> <tD VALIGN=TOP BGCOLOR=#FFFFFF HEIGHT= 90 WIDTH="400"><bR> <div><FONT SIZE="3" COLOR="#000000" FACE="Arial,Helvetica,sans-serif">Make your check payable to:  </FONT></div> <div><FONT SIZE="3" COLOR="#000000" FACE="Elephant"><B>Aviculture Microbioloy Foudation, Inc</B></FONT></div> <bR> </tD> </tR> <tR> <tD VALIGN=CENTER BGCOLOR=#FFFFFF HEIGHT= 164 WIDTH="400"><div><FONT SIZE="3" COLOR="#000000" FACE="Arial,Helvetica,sans-serif">Mail your completed application with your membership dues  to:</FONT></div> <bR> <div><FONT SIZE="3" COLOR="#000000" FACE="Arial,Helvetica,sans-serif">Aviculture Microbiology Foundation,Inc</FONT></div> <div><FONT SIZE="3" COLOR="#000000" FACE="Arial,Helvetica,sans-serif">Pam Suite, Treasurer</FONT></div> <div><FONT SIZE="3" COLOR="#000000" FACE="Arial,Helvetica,sans-serif">3065 S.E. Darien Road</FONT></div> <div><FONT SIZE="3" COLOR="#000000" FACE="Arial,Helvetica,sans-serif">Port St. Lucie, Fl 34952</FONT></div> <bR> <div><FONT SIZE="1" COLOR="#000000" FACE="Arial Black"><B>DONATIONS ARE TAX DEDUCTABLE</B></FONT></div> </tD> </tR> </TABLE></div> </div> <div><IMG BORDER="0" SRC="1x1.gif" HEIGHT="1" ALIGN="bottom" WIDTH="1" HSPACE="0" VSPACE="0" ></div> <bR> <bR> <bR> <div><FONT SIZE="4" COLOR="#000000" FACE="Chasm">You must follow the policies which will come to you through acceptance by Membership Committee.</FONT></div> <div><IMG BORDER="0" SRC="1x1.gif" HEIGHT="11" ALIGN="bottom" WIDTH="1" HSPACE="0" VSPACE="0" ></div> <div><FONT SIZE="4" COLOR="#000000" FACE="Chasm">Failure to comply according to the guidelines will result in termination/removal of your participation on the discussion list or as a member of Aviculture Microbiology & Foundation, Inc. </FONT></div> <bR> <bR> <bR> <div><FONT SIZE="1" COLOR="#000000" FACE="Arial,Helvetica,sans-serif"><I>No part of this publication may be reproduced, stored in a retrieval system, or transmitted, in any form or by any means, electronic, mechanical, photo-copying or otherwise, without permission of the copyright holders.</I></FONT></div> <div><FONT SIZE="1" COLOR="#000000" FACE="Arial,Helvetica,sans-serif">Copyright © 2007. All rights reserved by Aviculture Microbiology Foundation, Inc. <B>.   You  can  link to this website.  </B></FONT></div> </BODY> </HTML>  </B></div> <bR> <bR> <bR> <bR> <bR> <bR> <bR> <bR> <bR> <bR> <bR> <bR> <bR> <bR> <div>  Copyright © 1999-2007. All rights reserved by Cherane Pefley</div> </td> </tr></table></body>