MEMBERSHIP APPLICATION ®
Please complete both sides of this application. CHINA 2017 PROMOTION CODE
American Chemical Society | Member Services PO Box 82229, Columbus, OH, 43202-0229 U.S.A. T +1 [614] 447-3776 F +1 [614] 447-3891 Email
[email protected] H ome D r.
W ork P rof.
17China50Fpdf
Mailing address for delivery of C&EN and membership materials. (Please provide your full street address. This will enable us to ensure you receive your materials in a timely manner.) M r.
M rs.
M iss
M s.
Family Name/Last Name ______________________________ First Name _______________________________ Middle Initial _______ Primary Email Address ___________________________________________________________________________________________ (Required to activate certain member benefits)
Company/University Name _______________________________________________________________________________________ Job Title ______________________________________________________________________________________________________ Work/School Address ___________________________________________________________________________________________ City ______________________________ State/Country ______________________________ Zip/Post Code ____________________ Home/Summer Address _________________________________________________________________________________________ City ________________________________ State/Country ________________________________ Zip/Post Code ________________ Home Phone ___________________________________________ Office Phone ___________________________________________ Mobile Phone __________________________________
Birthday ___ M ___ M / ___ D ___ D / ___ Y ___ Y ___ Y ___ Y
Gender
M ale
F emale
MEMBERSHIP CATEGORY and DUES PAYMENT* (select one)
—ALL PRICES BELOW ARE IN U.S. DOLLARS— Your membership anniversary date will begin from the day your membership application is processed and will end one year later. R egular or Returning Members: A person who has a degree or certification in chemical or related sciences; or certification as a teacher of chemical science. Prior Membership # (if returning): _______________________________________________ on-Scientist/Society Affiliate: A person who is not eligible to become a member of the Society N but whose major vocational effort is directly concerned with the practice of a chemical science.
$83.00
________
$83.00
________
$42.00
________
$14.00 $27.00
________ ________
Not eligible for the free 1st year Technical Division offer.
raduate Student Member: A person who is a full-time graduate student, majoring in a chemical G science or a related academic discipline. ndergraduate Student Member: A person actively working toward an undergraduate degree U in chemistry or in a related academic discipline. Without C&EN Subscription With C&EN Subscription (See below C&EN delivery method.) Recent Graduate Discount: A person graduating with a bachelor’s degree in chemical science may apply for membership within one year from the date of graduation to receive a discount of 50% of the membership dues. Husband/Wife Dues: A spouse of a member who is receiving C&EN may deduct the 2016 allocation of $52.98.
Subtract 50% – $ Subtract $52.98 – $
PLEASE CHECK ONLY ONE C&EN DELIVERY METHOD C&EN print delivery via postal service
—OR—
Add $75.00 + $________
FREE C&EN Electronic delivery C&EN email address if different from above: _______________________________________ Technical Division subtotal (from side 2)
+ $________
PAYMENT INFORMATION Please charge my credit card:
Visa
FREE
Total Amount Due: ________ MC
Amex
Diners
Discover
Name on Card (please print): _________________________________________________________________________________ Authorized Signature: ______________________________________________________________________________________ Check made payable to American Chemical Society Bill Me Payment by international wire: Please add USD $20 for bank processing fees when paying by wire transfer. Include your MEMBERSHIP NUMBER or INVOICE NUMBER on the wire documents. Send to BANK OF AMERICA, 730 15th Street NW, Washington DC, 20005 USA. Include the ACS bank account number 002080589526, SWIFT code BOFAUS3N, and ABA routing/transit number 0260-0959-3. All monies must be in U.S. dollars. U.S. Federal Tax ID# is 53-0196572.
Please see other side.
M / ___ Y ___ Y ___ Y ___ Y CVV No.: |___|___|___| Card #: |___|___|___|___|___|___|___|___|___|___|___|___|___|___|___|___| Exp. Date: M ___ ___
17China
TECHNICAL DIVISIONS Your first Division selection is FREE for one year as a new member. Some restrictions apply. Visit acs.org/divisions to learn more and view subdivisions. My free Division selection is:__________________________________________________________________ Additional Divisions may be selected below and the associated dues amounts will be charged. 10 $ $14 $20 $20 $15 $20 12.50 $ $10 $15 $20
Agricultural and Food Chemistry Agrochemicals Analytical Chemistry Biochemical Technology Biological Chemistry Business Development and Management Carbohydrate Chemistry Catalysis Science and Technology Cellulose and Renewable Materials Chemical Education
$48 $15 $15 $18 $15 $21 $20 $15 $10 $10 $20 $14
Chemical Health & Safety(e) Chemical Information Chemical Toxicology Chemistry and The Law Colloid and Surface Chemistry Computers in Chemistry Division of Energy and Fuels Environmental Chemistry Fluorine Chemistry# Geochemistry History of Chemistry Industrial and Engineering Chemistry
$15 $25 $25 $15 $15 $30 $25
$10 $95 $15
Inorganic Chemistry Medicinal Chemistry Nuclear Chemistry and Technology Organic Chemistry Physical Chemistry Polymer Chemistry Polymeric Materials: Science and Engineering Professional Relations Rubber Small Chemical Businesses
Technical Division subtotal
$______
(carry over to side 1)
ACADEMIC TRAINING Name of College or University (including current enrollment)
City and State/Country
Curriculum Major
Title of Degree(s) Received or Expected A.S., B.S., M.S., Ph.D.
Month/Year Degree Received or Expected
__________________________________________________________________________________________________________________ __________________________________________________________________________________________________________________ __________________________________________________________________________________________________________________ __________________________________________________________________________________________________________________
INDUSTRY CODE/ NATURE OF BUSINESS Which best represents your industry/nature of business. L Public Utility/Transportation 1 Independent Laboratory M Retail/Wholesale Trade 2 Independent Consulting Y1 Pharmaceutical 3 Hospital/Clinic Y2 Biotech/Life Sciences Co 66 Academic Institution Y3 Environmental/Water J Engineering/Construction Firm Y4 Food/Beverage/Flavors K Government
Industrial Chemicals Y5 Y6 Agricultural Y7 Petrochemical Y8 Manufacturer Other: _______________________________ ZZ Other: _______________________________
We nominate the following candidate to be considered for membership in the American Chemical Society (ACS) and verify that this candidate, in accordance with ACS Bylaw I, Section 3, meets the qualifications for consideration for membership. ACS Member:
ACS Member:
_________________________________________________
__________________________________________________
Kate Fryer, Executive Vice President, Membership Division
Margaret T. Schooler, Chair, Membership Affairs Committee
MEMBER-ELECT (NOMINEE) AGREEMENT I attest to the accuracy of the information on the application. I agree to restrict for my own personal use all publications to which I subscribe at member rates. I understand that membership dues are payable annually unless my signed resignation is received by the Executive Director of the Society prior to the end of the 12-month period for which dues have been paid. Signature of Applicant
X ____________________________________________________________
Date ____________________
Please check here to opt-in for the ACS Member SciFinder™ Benefit. You must provide a valid primary email address to begin access to SciFinder™. Read the Terms & Conditions of SciFinder at www.acs.org/SciFiMemberTerms. Check here to opt-out of the ACS Network online member directory. *Includes a small allocation for Division funding. Members: 2017 $55.70 allocated to C&EN. (e) Includes a $36 subscription fee. # Not a participant of 1st year free program.
