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Membership Application Form - Word Document or PDF
Name: ................................................................... Address: ................................................................ ......................................................................... City/Suburb: ..................................... State: ............... Postcode: ................. Country: .................................... Telephone: ............................. Fax: ........................... E-mail address: ......................................................... Position held: .......................................................... Field of interest: ...................................................... (e.g. Photobiology, Molecular, DNA repair, Pathology, Wound repair etc) Suggested speakers for next conference: ................................. Student applicants only Supervisor (Name and Institute):......................................... Degree enrolled in:..................................... Year level: .... Type of membership: [ ] New membership [ ] Renewal [ ] Student membership $22 inc GST AUD [ ] Ordinary membership $55 inc GST AUD [ ] Corporate membership (please enquire)
New membership applicants please complete the following:
"I wish to become a member of the Molecular and Experimental Pathology Society of Australasia. In the event of my admission as a member, I agree to be bound by the rules of the Society."
Signature: ...................................... Date....................
I, ..............................................................
as member of the Society, nominate the applicant, who is personally known to me, for membership of the Society. (NB. This section can be completed on your behalf if required)
Signature: ....................................... Date....................
Send this application form with a cheque or money order made out to 'MEPSA' for the annual membership fee to:
A/Prof Terry Piva(Molecular and Experimental Pathology Society of Australasia ABN 97 829 237 070)