Membership Form

                     BALTNET Membership/Sponsorship Form

Yes, I would like to become a member of BALTNET and join in making vital connections between the Baltics and New England! (Check a box below for the type of membership.)

_ Individual Annual Membership - $50    _ Business/Corporate Annual Membership - $250

Name ____________________________________ Position _________________

Company/Organization______________________________________________

Mailing Address ___________________________________________________

________________________________________________________________

Phone  _______________________       E-mail  _________________________

_ Yes, I would like to support the future of BALTNET with a sponsorship gift.

_ Diamond Sponsor - $5,000         _ Platinum Sponsor - $2,500       _ Gold Sponsor - $1,000

_ Silver Sponsor - $500                  _ Bronze Sponsor - $150                

All sponsorship gifts will be listed on the BALTNET website (unless the donor wishes to be anonymous).

_ I/We wish this gift to remain anonymous.   

_ This gift is being made in memory of __________________________________________________.

If you prefer to designate your sponsorship gift to a specific project please check one or more of the boxes below.

_ Academic Exchange                        _ Innovative Projects Design & Implementation

_ International Collaboration & Research Programs        _ Professional & Cultural Exchange

THANK YOU FOR YOUR SUPPORT AND GENEROSITY!

Please make your check payable to BALTNET, Inc., and mail with this form to: Mrs. Regina Ziurys, Treasurer, 176 Amherst St.,

Wethersfield, CT 06109                         Phone: 860-529-7339