\documentstyle{article}

\begin{document}

\pagestyle{empty}
\begin{center}
{\large\bf International Society on General Relativity and Gravitation\\
MEMBERSHIP FORM \\
CORPORATE MEMBERSHIP ONLY}
\end{center}

When completed, mail this form to Professor M A H MacCallum, Secretary,
International Society on General Relativity and Gravitation, School of
Mathematical Sciences, Queen Mary, University of London, Mile End Road,
London E1 4NS, U.K. (or email to M.A.H.MacCallum@qmul.ac.uk).\\
\rule{6in}{.01in}\\
{\bf Please type, or write in block letters}\\
Title and name of responsible person:\\[12pt]
Department and Institution:\\[12pt]
Address for correspondence:\\[24pt]
Phone:\\
Fax:\\
Email:\\
I will accept Society communications via email:\hspace*{10pt} Yes/No \\
\rule{6in}{.01in}\\

We wish to obtain/renew corporate membership of the International
Society on G.R.G.  We are sending a remittance of ..............
Euros/US\$/Sw.Fr./GBP to cover the fees for ...........members (minimum
3; maximum 15), including .......... student members, for the period
...............(This will give the said Institution the right
to send this number of delegates to G.R.G. Society assemblies and
enjoy other membership privileges.)

Payment will be made by (mark the applicable one):\\
\begin{tabular}{llll}
  Bank transfer to Bern & $\Box$&   &  \\
   Cheque herewith & $\Box$ &        Cheque mailed to Penn State&
   $\Box$\\
   Visa credit card (details below)&$\Box$&
   Mastercard credit card (details below)&$\Box$\\
\end{tabular}\\[8pt]
Card number \rule{2.4in}{0.005in} with checksum
number\rule{1in}{0.005in} \\[3pt]
in the name of \rule{3in}{0.005in} expiring \rule{1.2in}{0.005in}\\[8pt]
We require a receipt for this payment: Yes/No\\[10pt]
Signature \hspace*{2in}         Place and date:
\end{document}
