The American Chemical Society
1981 MEMBERSHIP APPLICATION
1
APPLICANT Mr., Mrs. Dr., Ms., Miss Last. First. Middle Name
Mailing Address:
Number and Street .
City. State. Zip Code
2 ACADEMIC TRAINING Name of College or University (Including current enrollment)
City and State
Degree! s ) Received or Expected
Years Attendance
Curriculum
Date Degree Received or Expected
3 COURSES COMPLETED Please list completed courses (by title) in Chemistry and Chemical Engineering (Attach separate sheet or transcript if more space is needed.) Quarter hour credits should be multiplied by two-thirds. If school did not use a credit hour system, please estimate credits on basis of 15 lecture clock hours or 45 laboratory clock hours as equivalent to one semester hour credit. Semester Hours
Course Title
4
Course Title
Semester Hours
Semester Hours
Course Title
STATISTICAL INFORMATION Mr.. Mrs. Dr., Miss, Ms. Last. First. Middle Name
Mailing Address '. Number
and Street
City. State. Zip Code
C&EN
(Address must agree with that given above )
PREVIOUS MEMBERSHIP 1 have
5
D
have not
D
previously been a member.
Date of Birth
Sex
DF DM
PROFESSIONAL EXPERIENCE IN CHEMISTRY OR CHEMICAL ENGINEERING Employer
lob Title
(Please give present employer's city and state location)
Office AMC MJR DEL MED CSD
Use
Functions
% Time on Chemical Work
Inclusive Dates of Employment (Mo & Yr I
Please return completed application to:
Only CLD _ CNS _ CNR _ TEC _ WTD _
(If blank return to the American Chemical Society, 1155 16th St., N.W., Washington, D.C. 20036) (202) 872-4600
6
NOMINATION Please obtain the signatures of two ACS members* We recommend
for membership in the American Chemical Society. (name of applicant)
ACS member: (signature)
(printed name)
(signature)
(printed name)
ACS member:
7 STUDENT DISCOUNT
If you are a student majoring in chemistry, chemical engineering, or a related discipline, you are entitled to a 5 0 % discount for membership dues while registered for at least six credit hours as an undergraduate or doing full-time graduate work. If you wish your membership to begin on July 1, you are entitled to the discount only if enrolled for the college year next following the initial date of membership. I am
D an undergraduate student enrolled as described above. D a graduate student enrolled as described above.
(Name of College or University)
This space for use of: ADMISSIONS COMMITTEE 1
2
3
4
8
Ν
DUES
Please fill in amount Calendar Year Six Months (Eff. July 1) (Eff. January 1)
$52.00** for calendar year beginning January 1, 1981
$
$26.00 for six months starting July 1, 1981 $26.00*** (eligible students only —see item —7) for calendar year beginning January 1, 1981
$ $
$13.00 (eligible students only— see item —7) for six months beginning July 1, 1981 $39.00 National Affiliation for calendar year beginning January 1, 1981
$ $
$19.50 National Affiliation for six months beginning July 1, 1981
$ .
Reinstatement fee $10.00 (required of former members who did not resign within the stipulated time)
$
$
O t h e r (e.g. P u b l i c a t i o n s , Divisions, etc.)
$
$
Total amount enclosed
$
$
Husband/Wife Dues ** For the spouse of a member receiving C&EN and not wishing another copy, dues $40.00 (full year) $20.00 (half year) *** $20 00 (full year) $10.00 (half year) eligible students only
D Payment enclosed. (Payable to American Chemical Society) Charge my D Master Charge D VISA Account No. Expire date
Interbank No. (Master Charge only)
Signature Foreign payments must be made in U.S. currency, International money order, UNESCO coupons, or draft on a U.S. bank. * If this presents difficulty, please contact the Washington office.
