Application for (check one)

[ ] Ordinary Membership @ $75
[ ] Corresponding Membership @ $75
[ ] Post Doc Membership @ $50
[ ] Student Membership @ $30
[ ] Emeritus Membership@ $20

Do not send membership dues now. You will be billed upon acceptance of membership.

All applicants must enclose a current Curriculum Vitae or NIH Biosketch listing publications.

Name__________________________________________________________________________
                    Last                                         First                                               Middle

Current Position ___________________________________________Degree(s)_______________

_______________________________________________________________________________

Institution________________________________________________________________________

Mailing Address___________________________________________________________________

________________________________________________________________________________

________________________________________________________________________________

Country__________________________________________________________________________

Telephone: __________________________________Fax # ________________________________
     (if outside the USA;  please include country code)

E-mail: __________________________________________________________________________

I am a citizen of [ ] or currently reside in [ ] _______________________________________________

Gender: M F:_______
Academic Rank:_______________
Minority:__________________

Applicants for Ordinary membership must reside on the American Continent.

I share the aims of the American Society for Neurochemistry and understand that the Society
reserves the rights to assign me the category of membership that appears most appropriate
for my qualifications.
 

Signed _______________________________________Date _____________________________

This application must be signed by one Ordinary Member of the Society.

Signature __________________________________Name (typed or printed)_____________________
                       Supporting Sponsor

Send original and 4 copies to:    

American Society for Neurochemistry
attn: Ms. Sheilah Jewart
Amazing Occasions, Inc.
9037 Ron Den Lane
Windermere, FL 34786
Phone/Fax 407-876-0750
Email: amazing@iag.net

06/15/2000