CRYONICS INSTITUTE
24355 Sorrentino Court, Clinton Township MI 48035
Phone 1-586-791-5961, Phone/Fax 1-586-792-7062, E-Mail <cryonics@cryonics.org>

MEMBERSHIP APPLICATION

LIFETIME MEMBERSHIP

Name(s)_________________________________________________________________________

Address_________________________________________________________________________

________________________________________________________________________________

Telephone_______________________________Fax______________________________________

E-Mail Address____________________________________________________________________

Date of Birth of Applicant________________________________ Gender of Applicant:  M  /  F  (circle)

Date__________________________ Fee(s) enclosed______________________________________

Signature of Applicant_______________________________________________________________

Signature of Parent/Guardian if Applicant is a minor_________________________________________

The membership fee is a one-time payment of $1,250 for an individual or $1,875 for a couple (two in the same household). There is no extra membership fee for minor children, including children born or adopted after the parent has become a member. Additional close family members (spouse, siblings, parents, children) may join with a membership fee of $625 each. Membership is permanent, without payment of dues. Membership confers the right to execute a contract, the right to annual financial statements, the right to stand for office according to the By-Laws, and the right to notices and reports of meetings.

Membership fees are not refundable or transferable, in whole or in part.

For this option (Lifetime Membership), minimum contract funding (whole body) is $28,000, a one-time fee payable approximately at time of death or earlier, by life insurance or other means specified in the contract.

Membership in CI does not include membership in the Immortalist Society, but for the foreseeable future includes a subscription to The Immortalist. A full membership in the Immortalist Society costs $75. For full membership in the Immortalist Society, please add $75 and check here [ ].

Please send in your membership application with check enclosed. We can accept credit card payments for membership by phone, in writing or through Paypal (www.paypal.com, payable to CIHQ@aol.com).