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	Yes, please put me on your mailing list No, not at this time

Title	First name(s)	Last name
(Title = Mr./Ms./Dr./etc.)

Year of birth: (only the year, not your complete birthday)

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Email address:

If you have a website relevant to PERMANENT, or else a personal link about yourself or your organization, then you may list it here. It does not need to be relevant to PERMANENT, just to you.
Web link:

If you entered a web link above, please tell us whether we should consider inclusion in the PERMANENT website, and if so, just a very brief summary of website subject matter.

	No, not relevant to PERMANENT Yes, subject:

Areas of skill, experience and/or serious interest: (web programming / art / PR / engineer / etc.)

Affiliations with any other organizations:

PERMANENT related areas of PRIMARY expertise or serious interest:

Lunar bases Asteroid resources	Propulsion in space Earth launch	Habitats in orbit Biological systems	Products in orbit Industry in orbit	Business Politics
Other(s):

Company of employment / self employment / academic institution / other organization:

Position / Job Title / responsibility in your organization:

Address: (line 1)
(this is kept private)

Address: (line 2)
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City	State/Province	Postal code	Country
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Only city, province/state, and country are posted publicly.

Home phone:		(this is kept private)
Work phone:		(this is kept private)
Mobile phone:		(this is kept private)

Please elaborate about your own work, organization, interests, skills, commitment level, and any other comments. This field is intended to be a public field so that others can get to know about you and/or your organization. For anything private, please send email instead.

These two fields below are private and for our administrative use only, not public:

How did you find out about PERMANENT?

How serious are you about helping PERMANENT or a related organization? (not necessarily for PERMANENT)

Space development is my primary occupation or a most serious commitment in my life Major commitment - I will give as much time and effort as I can afford, and am very serious I don't have much time, but I will contribute my skills as best I can I can chip in a little bit of time, but don't want to take too much of your time I have no time right now, but might in the future, and here's my information for the record I will have no time, and right now just sending some information to you.