NEW MEXICO NETWORK FOR WOMEN IN SCIENCE AND ENGINEERING
Membership Form
October 1 through September 30
| Name:___________________________________________ | Date:____________________ |
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Please Check One: ____  New Membership____ Membership Renewal____ Information Change Only
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I am enclosing: ____ $40 Professional____ $10 Student / Teacher /Retired / Non-employed____ plus $_________ Donation
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Occupation: |
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Employer: |
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Work Address: |
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Home Address: |
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E-mail Address: |
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Telephones: |
Day: _____________________ Evening: _____________________ |
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FAX: _____________________ Cell/Alt: _____________________ |
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Preferred Mailing Address:
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____ Home | ____ Work | ||
| Preferred Newsletter Option: | ____ Email | ____ Mail |
Education
| School:_______________________ | Maj:_____________________ | Deg:_____ | Yr:_____ |
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School:_______________________ |
Maj:_____________________ |
Deg:_____ |
Yr:_____ |
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School:_______________________ |
Maj:_____________________ |
Deg:_____ |
Yr:_____ |
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 _________________________________________ | ||
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Indicate the local chapter with which you wish to be affiliated
Mail completed form and your dues to:
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