CAPNET: the child abuse professional network
membership registration form


Please provide all information requested

Charter Rates are still in effect! Act soon! Rates are subject to change without notice

First Name

Last Name
Title (degree)
Phone
FAX
Organization
Address Line One
Address Line Two
City
State/Province
Zip/Postal Code
Email
Note
Please provide the name, address e-mail, and phone number of an individual who can vouch for your status as a professional in the field of child abuse and neglect.
"Please Contact the Following Person who can vouch for me!"
Sponsor Name

Address

E-mail

Daytime Phone Number

subscription request

Non-US subscribers: please account for currency conversions AND add $25US to cover bank transfer fees.
PERSONAL PAYMENTS (more economical)
Regular Subscriber:

US$120/year (credit card only)


Charter Subscriber

US$100/year (credit card payment)
Personal Check for US$100 enclosed (Print/Fill form; Payable to LifeNET)

Credit Card Info MasterCard Visa
Card Number: - - -
Expiration Date:

INSTITUTIONAL PAYMENTS (less economical)
Institutional Rate US$160/year (group rates upon request)
Payment Method Purchase Order Voucher
Check this box! I agree to abide by the Terms and Conditions for this subscription.


For Check payments: Print/Fill; Mail to LifeNET, 210 Eddy Street, Ithaca, NY 14850

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