P.O.

Box 82229, Columbus, OH 43202-0229

2010 MEMBERSHIP APPLICATION

IMPORTANT NOTE: You must complete the entire application. Please do not leave out information. Incomplete information will slow down your admissions process.
I Dr. I Mr. I Mrs. I Miss I Ms. I Prof.

Last Name __________________________________________ First Name _____________________________________________ Middle Initial ______________ I Home I Work 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.)

Company/University Name ________________________________________________________________________________________________________________ Job Title ________________________________________________________________________________________________________________________ Work/School Address ____________________________________________________________________________________________________________________ City __________________________________________________ State/Country ________________________________ Zip/Postal Code ____________________ Home/Summer Address (May 15th Aug. 15th) ______________________________________________________________________________________________ City __________________________________________________ State/Country ________________________________ Zip/Postal Code ____________________ Home # ____________________________________________________ Office # ____________________________________________________________
(Area Code) (Area Code)

Fax # ______________________________________________________________________________
(Area Code)

Office E-mail __________________________________________________________________________ Home E-mail __________________________________________________________________________

For more information:

CALL (800) 333-9511 or (614) 447-3776 FAX (614) 447-3891 E-MAIL service@acs.org WEB www.acs.org/joinACStoday

ACADEMIC TRAINING Name of College or University (Including current enrollment) City/ State or Province/Country Curriculum Major Title of Degree(s) Received or Expected A.S., B.S., M.S., Ph.D. Month/Year Degree Received or Expected

____________________________________________________________________________________________________________________ ____________________________________________________________________________________________________________________ ____________________________________________________________________________________________________________________

DEMOGRAPHIC INFORMATION (optional)

We ask you to provide the following voluntary information. The American Chemical Society is eager to support programs that benefit underrepresented groups in the chemical sciences, and your responses are helpful to these efforts (and to all facets of our services to all of our members). Individual responses are held in strictest confidence and have no bearing on consideration for membership. Racial-ethnic origin (please check one only): K White (Caucasian) K American Indian or Alaskan Native K Black or African Descent K Native Hawaiian or Pacific Islander K Hispanic K Other K Asian Date of Birth__________________ Sex: K F K M
MM/DD/YYYY

MEMBER CATEGORIES
Regular Member: A person that has a degree or certification in chemical or related sciences; or certification as a teacher of a chemical science. Graduate Student Member: A person who is a full-time graduate student, majoring in a chemical science or a related academic discipline. Undergraduate Student Member: A person actively working toward an undergraduate degree in chemistry or in a related academic discipline. Non-Scientist/Society Affiliate: A person who is not eligible to become a member of the Society but whose major vocational effort is directly concerned with the practice of a chemical science.

Members Outside of North America may choose to receive C&EN electronically. We must have your accurate email address. If for any reason we are unable to deliver your C&EN electronically, we will reinstate the print version after 90 days, and you will be billed the 58USD in postage charges. Check your C&EN delivery option on the other side of this form.

FOR OFFICE USE ONLY MG BC ____________ HDL __________________ MJR ______________ DEL ______________ SOURCE 10JOINpi ______________________________

THIS SPACE FOR USE OF ADMISSIONS COMMITTEE

LOCAL SECTION/DIVISION COMMISSION CLAIM

NAME OF EXHIBIT/MEETING WHERE SUBMITTED

10-APPS

CHOOSE YOUR DIVISION FIRST ONE IS FREE FOR ONE YEAR

The first selection is free* for first-time, new members; additional selections will be billed. My free Division selection is___________________________________. I understand I may also join additional Divisions and be billed along with my membership dues. (Check additional selections below.) K Agricultural and Food Chemistry K Agrochemicals K Analytical Chemistry K Biochemical Technology K Biological Chemistry K Business Development and Management K Carbohydrate Chemistry K Catalysis Science and Technology (probationary)* K Cellulose and Renewable Materials K Chemical Education K Chemical Health and Safety K Chemical Information K Chemical Toxicology K Chemistry and the Law K Colloid and Surface Chemistry K Computers in Chemistry K Environmental Chemistry
*Excludes probationary divisions.

MEMBERSHIP CATEGORY & DUES PAYMENT*

J Regular or Returning Member
145.00USD $___________

Prior Membership #___________________________________

J Graduate Student Member J Undergraduate Student Member: J With print or electronic delivery of C&EN J Without C&EN J Non-Scientist/Society Affiliate

72.50USD

$___________

K Fluorine Chemistry K Fuel Chemistry K Geochemistry K History of Chemistry K Industrial and Engineering Chemistry K Inorganic Chemistry K Medicinal Chemistry K Nuclear Chemistry and Technology K Organic Chemistry K Petroleum Chemistry K Physical Chemistry K Polymer Chemistry K Polymeric Materials: Science and Engineering K Professional Relations K Rubber K Small Chemical Businesses

45.00USD 24.00USD 145.00USD

$___________ $___________ $___________

*Includes a small assessment for Division and Local Section funding. Members: 41.68USD allocated to C&EN.

_____________________________________________________ J Recent Graduate Discount

A person graduating with a bachelors 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. Graduation date: _____________ Subtract 50% $<________>
(from total above)

$___________

J Husband/Wife Dues If you are the spouse of a

member receiving Chemical & Engineering News, you may deduct 41.68USD of your dues allotted for C&EN. Spouse name/Member #: ____________________________________ Subtract 41.68USD $<________>
(from total above)

_____________________________________________________

Please Check Only One C&EN Delivery Method

J C&EN print delivery via postal service at a cost of 58USD Add 58.00USD +$__________ OR J SAVE 58USD C&EN Electronic delivery via e-mail Valid e-mail address required FREE e-mail __________________________________________________

INDUSTRY CODE/NATURE OF BUSINESS

K 63 Pre-College K 64 Two Year College/ Tech School K 65 Four Year Univ/College K J Engineering/ Construction Firm K Q Financial Institution K K Government K 3 Hospital/Clinic K 2 Independent Consultant K 1 Independent Laboratory K Y Manufacturer K U Membership Organization K T Newsdealer/Bookseller K V Public Library K L Public Utility/ Transportation K M Retail/Wholesale Trade K ZZ Other_____________________

TOTAL AMOUNT TO BE PAID $________

J Check made payable to American Chemical Society J Charge my credit card: J Visa J MC J Amex J Diners J Discover Card # |___|___|___|___|___|___|___|___|___|___|___|___|___|___|___|___| Expiration Date |___|___|/|___|___|___|___|
month year

Name on Card ________________________________________________________

(please print)

Signature _____________________________________________________________ J Bill me

NOMINATION
We nominate this Applicant for membership in the American Chemical Society according to the Constitution and Bylaws. ACS Member: D. Richard Cobb, Chair Membership Affairs Committee ACS Member: Denise L. Creech, Director Division of Membership and Scientific Advancement

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

Date

Your membership will begin from the date your membership application is processed and will end one year later. This will be your anniversary date.