Geothermal Energy Association Membership Payment form

	GEOTHERMAL ENERGY ASSOCIATION

Membership Payment form

Methods of Payment Payments to be made in US dollars.	Today is: 9/3/2010
CHECK - if paying by check, please made payable to: Geothermal Energy Association
Check number: Date: Ammount:
WIRE TRANSFER - If you need to make a payment via wire transfer, please contact GEA for instructions. A copy of the wire transfer must be submitted with the exhibit application.
CREDIT CARD
Type
Card Number
Name as it appears on the card
Expiration Date (mm/dd/yy)
I authorize the Geothermal Energy Association to charge to the account identified abovethe amount of $:
I prefer a confirmation by:

e-mail at
fax at
Please complete this form, print it out and Fax it at (202)454-5265

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