New Membership: _______                                               Membership Renewal: ________

Membership Level:        President       ($10,000) ________ (Primary plus nine designees)
                             Ambassador    ($5,000) ________ (Primary plus four designees)
                             Diplomat          ($2,500) ________ (Primary plus one designee)

  Name and Title (Primary Designee)*: ___________________________________________

  Organization: ______________________________________________________________

  Mailing Address: ____________________________________________________________

                            ___________________________________________     Zip: ___________

  Phone: _______________  Fax: _________________  E-mail:________________________

  __ I want to help WorldBoston reduce its mailing costs.  Please send all correspondence via email.

*Please provide contact information for Primary Designee and attach contact information
  for any additional designees on a separate sheet or on the reverse of this form.

Payment:

__  Check enclosed (made payable to WorldBoston)

__  Charge my Visa / MasterCard / AMEX:_____________________________________ Exp.: ___/___

                                                         Membership           $_________

                                                         Contribution**      $_________

                                                         Total Enclosed      $_________

** I understand that my member dues help defray the cost of providing member benefits. 
         Therefore I also wish to make a tax-deductible contribution to WorldBoston.