Application Form

If you would like to take the Mensa Admissions Test, you do not need to complete and return this application. Instead, please request testing information in your area. You will receive communication containing additional details and contacts for testing in your area. A testing fee of $40 (U.S.) will be due to the proctor at the time of testing.

To submit evidence of prior testing, please complete this form, print and mail to the address listed below.

First Name:
Last Name:
Address 1:
Address 2:
City:
State:
Zip + 4:
Home Phone: (please include area code)
Business Phone: (please include area code)
Date of Birth:	Month Day Year
Email Address:
Gender:	Male Female

I claim exemption from testing and enclose prior evidence of intelligence test scores in the top 2% of the general population. Prior evidence submitted must be a notarized copy or original documentation. All other evidence will NOT BE ACCEPTED. Please refer to our information on prior evidence. I understand that this is a non refundable evaluation fee.

$40.00

Additionally, I would like to pay my first year's dues ($79.00, expires 3/31/2011) at this time. My dues include fixed amounts for: my Mensa Bulletin subscription, my Local Group newsletter subscription, and Local Group support. If the prior evidence I submit is not acceptable, I understand that this amount will be refunded.

$79.00

Enclosed is a check, money order, or credit information for:

$ (U.S.)

To pay by Visa, MasterCard, American Express, or Discover complete the following credit information:

Type:	Visa MasterCard Discover Amex
Card Number:
Expiration Date:
Security Code:	what's this?

Authorized Signature: ________________________________
Credit information must be accompanied by authorizing signature.

Name of special promotion (if applicable) :

Make your check or money order payable to American Mensa, Ltd. All payments must be drawn in U.S. funds. Please allow 2-4 weeks for processing of application. Print and mail this form to:

American Mensa, Ltd.
1229 Corporate Drive West
Arlington, TX 76006-6103

Phone:(817) 607-0060
Fax: (817) 649-5232