Membership Application Form

Please complete the following: ( * indicates a required field):

PERSONAL INFORMATION

	Prefix * :		Dr.
			Mr.
			Mrs.
			Ms.

	Last Name * :

	Given Name(s) * :


	Address * :

	Address2 * :

	City * :

	State/Province * :

	Country * :

	Zip/Postal Code * :

	Home Telephone * :		( )

	E-mail Address * :

	Date of Birth * :		D / M / Y (ex: 18 / 04 / 1950)

	EDUCATION * : (Curriculum Vitae (resume) must be submitted if you are an applicant educated outside of Canada) [Institution; Dates From/To; Course; Diploma/Degrees]

EMPLOYER INFORMATION


	Name of Employer * :		(or type"none" if unemployed)


	Address of Employeer :

	Address2 :

	City :

	State/Province :

	Country :

	Zip/Postal Code :

	Telephone :		( ) Extension:[ ]

	Fax :		( )

	E-mail Address :

	Product and/or function of employer :

	EMPLOYMENT * : (Applicants from outside of Canada must submit Curriculum Vitae (resume).) [Employer; Position; Date From/To]

	Area of Expertise * :

	Other Professional or Scientific Affiliations :

MEMBERSHIP INFORMATION

FREE DIVISION CHOICES * :

Please choose your
primary Division:

Check additional divisions:

PRIM		SEC
	Analytical
	Biological / Medicinal
	Biotechnology
	Catalysis
	Chemical Education
	Economics and Business Management
	Energy
	Environment
	Inorganic
	Materials
	Macromolecular Science and Engineering
	Organic
	Physical and Theoretical
	Process Safety Management
	Rubber
	Surface Science
	Systems and Control
Other:
	Canadian Green Chemistry and Engineering Network

Please indicate if you wish to purchase a discounted publication:

	Process Safety & Environmental Protection (IChmeE) $270.00

	Chemistry and Industry (SCI) $23.60

	Laboratory Helth and Safety Guidelines

The Canadian Jounal of Chemical Engineering:

	Print $125.00

	Online $75.00

	Both $150.00

The Canadian Journal of Chemistry:

	In Canada $170.00

	Outsude Canada $235.00

Previous Publication Choices:

If you wish to make contibution please indicate the amount:

	*Norman and Marion Bright Memorial Fund:

	* CIC Chemical Education:

	R.S. Jane Memorial Fund:

	Public Understanding of Chemistry:

Declaration: By submitting this form, I hereby certify that the foregoing statements are correct and are made as a condition of admission to membership. If accepted, I agree to be governed by the Charter, By-laws and regulations of the said Societies as they now or may hereafter become, and I undertake to promote the objects and interests of the CIC and Societies. CIC and Society membership is not refundable or transferrable.

Sponsor Verification:
Please supply information on a sponsor (a person in a position of responsibility, e.g. employer, supervisor, professor and, preferably, a member of the CIC).

	Name * :


	Address * :

	Address2 * :

	City * :

	State/Province * :

	Country * :

	Zip/Postal Code * :

	Telephone * :		() [Extension: ]

	E-mail Address * :

I paid my membership fee with CSC Conference Registration

Transaction code CSC

I paid my membership fee with CSChE Conference Registration

Transaction code CSChE