Membership Form

Personal Information

Salutation:………………….

First Name: ……………………………     

Last Name: ……………………………

Occupation: ……………………………

Title:  ……………………………

Discipline: ……………………………

Affiliation: ……………………………

Department: ……………………………

Work Phone: ……………………………

Cell Phone: ……………………………

Email:  ……………………………

 

Address Information

For Mailing

Address: City: ……………………………

State: ……………………………

Postal Code: ……………………………

Country: ……………………………

For Roster (if different)

Address: ……………………………

City: ……………………………

State: ……………………………

Postal Code: ……………………………

Country: ……………………………

 

Research Interests

Description (max 30 characters):

 

Payment

Annual Membership (select one):  $10 Student Member      $20 Member

Lifetime Membership:  $300 Member

Additional contribution (optional): ________

Total Donation: ___________

Submit payment via paypal AND email this completed membership form to: Chiara Diana Chiara.Diana@ulb.ac.be

(If you are unable or prefer not to remit payment via paypal, please contact Heidi Morrison at hmorrison@uwlax.edu)

AMECYS Student Membership

$10.00

AMECYS Membership

$20.00

AMECYS Lifetime Membership

$300.00