Please provide the following contact information:

First Name
Last Name
Middle Initial
Title
Organization
Street Address
Address (cont.)
City
State/Province
Zip/Postal Code
Country
Work Phone
Home Phone
FAX
E-mail

      Regular Member                         Payment Schedule

           Individual                        Monthly $15.00 Annually $180.00

           Family                            Monthly $25.00 Annually $300.00

           Student/Senior                 Monthly $10.00 Annually $120.00

            Regular members receive 10% discount on tuition, books and dharma items!

      Special Friends

           Lotus Benefactor                   $700.00 Annually
                              Plus receive 20% discount

           Jewel Benefactor                   $1,400.00 Annually
                              Plus receive 25% discount

           Vajra Benefactor                   $2,100.00 Annually
                              Plus receive 30% discount

Please select payment method (U.S. dollars):

            Check __________   (We will send you a reminder notice monthly)
             Direct Deposit from my bank account, on or after 15th of each
                   month. Contact me for Longchenpa's account number.
                       Make check or money order payable to: Longchenpa Institute
                       Mail to 17 Vincent Street, Binghamton, NY 13905 

             Credit Card Billing Information - Please Submit the Form first .

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