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Membership Application Form




American Synesthesia Association, Inc.
90 Morningside Drive, 3B
New York, NY 10027


Please fill out the following:

First Name: ___________________________________
Last Name: ___________________________________
Street Address: ___________________________________
City, State, Zip: ___________________________________
Telephone Number: ___________________________________
Fax Number: ___________________________________
E-mail Address: ___________________________________
Website: ___________________________________

Please select from one of the following categories of ASA membership:

Voting Members:
___ GENERAL (must be at least 18 years of age) $50 annual dues
___ SUSTAINING (must be at least 18 years of age) $500 annual dues
___ PATRON (must be at least 18 years of age) $1,000 annual dues
___ LIFETIME (must be at least 18 years of age) $5,000 one time only

The ASA is a not-for-profit, tax exempt organization whose educational mission encourages people to learn more about synesthesia. It is membership supported, so by becoming a member you will actively support this work. We encourage you to join the ASA, and we hope you can attend our upcoming national conference.


Method of payment:

Membership is ONLY for U.S. Citizens over 18 years of age:


Via Credit Card:


Annual Membership
Member Name
Member Email
Note: You do not need to pay via a Paypal account; simply click Pay with Debit or Credit Card.


Via Check or Money Order:

Please print out a copy of this membership, fill it out, and send it with your check or money order via regular mail to:

American Synesthesia Association, Inc.
90 Morningside Drive, 3B
New York, NY 10027


 Please make your check or money order payable to the American Synesthesia Association, Inc.