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ACS Membership Application

1986 Applicant

Mr., Mrs . D r . , M Î S S , M s . (Please type or print) Family Name

Mai l ing A d d r e s s Number and Street

City

Off i ce

T e l e p h o n e H o m e Zip Code/Country

Academic Training Name of College or University (Including current enrollment) City and State

Curriculum Major

Years of Attendance

Title of Degree(s)

Received or Expected

Date Degree Received or

Expected

Courses Completed Not required of those with a bachelor's, master's or doctor's degree in a chemical science or those with a doctor's degree in a science closely related to chemistry with demonstrated significant experience in the practice of a chemical science. Please list c o m p l e t e d c o u r s e s (by t i t le ) in t h e c h e m i c a l s c i e n c e s (A t t ach s e p a r a t e s h e e t o r t r a n s c r i p t if m o r e s p a c e is n e e d e d . )

Q u a r t e r h o u r c r e d i t s s h o u l d b e m u l t i p l i e d b y t w o - t h i r d s . If s c h o o l d i d n o t u s e a c r e d i t h o u r s y s t e m , p l e a s e e s t i m a t e c r e d i t s o n bas i s of 15 l e c t u r e c l o c k h o u r s o r 4 5 l a b o r a t o r y c l o c k h o u r s as e q u i v a l e n t t o o n e s e m e s t e r h o u r c r e d i t .

Course Title Semester

Hours Course Title Semester

Hours Course Title Semester

Hours

Nominat ion A l t h o u g h n o m i n a t i o n b y 2 ACS m e m b e r s is r e q u i r e d b y ACS b y l a w s , if t h i s p r e s e n t s d i f f icul ty , w e sugges t y o u c o n t a c t t h e W a s h i n g t o n off ice. In a n y ca se , s u c h n o m i n a t i o n is n o t n e c e s s a r y for f o r m e r m e m b e r s ( s t u d e n t aff i l ia t ion d o e s n o t c o n s t i t u t e m e m b e r s h i p ) .

W e r e c o m m e n d .

ACS M e m b e r : _

ACS M e m b e r : _

(Name of Applicant) for m e m b e r s h i p in t h e A m e r i c a n C h e m i c a l Soc ie ty .

(Signature) (Printed Name)

(Signature) (Printed Name)

This space for use of: ADMISSIONS COMMITTEE

Statistical Information Mr., Mrs. ί ; D r M i s s M s (Please type or print) Family Name First Middle

Mailing Address Number and Street Office Use OI1I3

A M C City State Zip Code/Country _ ^ '

DEL Office

Date of Birth Sex Π F D M Telephone (Information needed for statistical purposes) Home

Prev ious Membership I have Π have not • previously been a member. I have Π have not Π previously been a student affiliate.

Professional Experience WTD

% Time on Inclusive Dates of Employer Job Title Functions Chemical Work Employment (Mo. &Yr.)

Dues/Subscriptions/Divisions There are four start dates for membership: 1 January, 1 April, 1 July, and 1 October. We are anxious to begin your membership as soon as possible and will therefore enroll you immediately upon approval of your application by the ACS Admissions Committee. Dues for 1986 are $72.00. If you subscribe to publications, the amount will be prorated, unless you indicated that you wish the full year's subscription. Your membership will begin at the nearest quarter and you will be billed accordingly. Those entering 1 October will be billed for three months of the year plus the full dues for the following year (or 15 months dues) or at the new member 's option, may pay for the final three months of the current year only. Former members who did not resign will be assessed a S 10.00 reinstatement fee. Please send no money now. Student D u e s If you are a student majoring in the chemical sciences a 50% reduction on membership is available. To apply you must be registered for at least six credit hours as an undergraduate or be enrolled as a full-time graduate student. I am D an undergraduate student enrolled as described above.

D a graduate student enrolled as described above. Name of College or University

National Affiliation National affiliates pay three-quarters dues (i.e. $54.00) and likewise will receive a prorated bill based on the quarter national affiliation begins. Husband/Wife D u e s If you are the spouse of a member receiving C&EN, 2 3 % (or the prorated amount) will be deducted from your bill. This is the port ion that is allotted for C&EN. If you are eligible, please give the name of your spouse and his/her membership number.

Spouse's Name Membership Number

If you wish to subscribe to an ACS publication or join an ACS division please list the publication(s)/division(s) below.

Remember , s e n d n o m o n e y n o w .

Agreement 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 before January 1 of the year for which the resignation is to take effect.

(Date) (Signature of Applicant)

IUPAC Affiliation Beginning in 1986, the International Union of Pure and Applied Chemistry (IUPAC) is offering individual Affiliation to members of national chemical societies. Recognized by all the sciences and by the national level academies of science as the international representative body for chemistry, IUPAC is the authority on chemical nomenclature, terminology, symbols, atomic weights, and related topics. IUPAC Affiliate Dues for ACS members residing in the U.S. are $ 15.00 and include a subscription to Chemistry International magazine.

D IUPAC Affiliation $15.00 (U.S. members only)