NMNWSE Membership Form

NEW MEXICO NETWORK FOR WOMEN IN SCIENCE AND ENGINEERING

Membership Form

October 1 through September 30

Name:___________________________________________

Date:____________________

Please Check One	____	New Membership	I am enclosing:	____	$25 Professional
	____	Membership Renewal		____	$15 Retired
	____	Information Change Only		____	$ 5 Student/ Unemployed
				plus	$_______ Donation

Occupation:	_______________________________________________________
Employer:	_______________________________________________________

Work Address:	____________________________________________________
	____________________________________________________
	____________________________________________________
Home Address:	____________________________________________________
	____________________________________________________
EMail Address:	____________________________________________________

Telephone:

Day:

____________________

Evening:

_________________

FAX:

_________________

Preferred Mailing Address:	____ Home	____ Work
Preferred Newsletter Option:	____ Email	____ Mail

Education
School:	_____________________	Major:	______________________	Degree:	_____	Year:	_____
School:	_____________________	Major:	______________________	Degree:	_____	Year:	_____
School:	_____________________	Major:	______________________	Degree:	_____	Year:	_____

Please identify your interests. (Please circle Primary choice)
____	Anthropology	____	Computers	____	Management
____	Astronomy	____	Education	____	Mathematics
____	Biology	____	Engineering	____	Medical Sciences
____	Business	____	Geology	____	Physics
____	Chemistry	____	Health Sciences	____	Psychology
	____ Other	_________________________________________

Indicate the local chapter with which you wish to be affiliated		Internal Use
____	Northern (Los Alamos Area)	Action	Date
____	Central (Albuquerque Area)	Action	Date
____	Eastern (Portales Area)	dues received	________
____	Southern (Las Cruces and Silver City Area)	database change received	________
		database changed	________
Mail to:		sent to local president	________
	New Mexico Network for Women in Science and Engineering P.O. Box 1360 Los Alamos, New Mexico 87544