NEBASM  MEMBERSHIP  FORM

NEB/ASM members receive newsletters, meeting announcements, job placement assistance and annual meeting discounts.  Invite your colleagues to join NEB/ASM so that they too will be able to participate in our branch activities.

This is a renewal membership ___ or a new membership ___ 

National ASM member _____ (please answer 'Y' or 'N').  ASM number ___________

ASM Division ___________________________

Name: ____________________________________________________________
                                (Last)                             (First)                                (Mid. Int.)

Business Address:   __________________________________________________
                                 __________________________________________________
                                 __________________________________________________
                                 __________________________________________________
    Telephone:           __________________________________________________

Home Address:       __________________________________________________
                                 __________________________________________________
                                 __________________________________________________
    Telephone:           __________________________________________________

Please indicate preferred mailing address.  Home ___ or Business ___

E-mail:                      __________________________________________________

Education:  Degree:_____  Year Awarded: ________  Institution: ____________

Professional position: ________________________________________________

Primary area of interest: Education ___;  Biotechnology___;  Clinical/Public Health___;              Industrial ___;   Marketing/sales ___;  Other (please specify) ___________________________________

Are you interested in participating in Branch activities?

Presenting papers ___;  Leading workshops/seminars ___;  Participating in round tables ___;    Working on committees ___;  Running for Office ___;  Other (please specify) __________

FEES:  Membership Categories:  Individual ($15 annually, $40 / three years)  Student: ($10 annually)  Emeritus (no charge)

Please print out this form,  fill in all areas, make your check payable to:  NORTHEAST BRANCH/ASM  and mail to: 
Irene George
MASS Center for Disease Control
State Laboratory Institute  Rm 756
305 South Street, Boston, MA 02130

Thank you for joining the Northeast Branch !