ISM Membership Information

(    )  New Membership $30 - 2 years

(    ) Emeritus Member

(    ) Apply for Emeritus status

Dr./Mr./Ms./Mrs.:

Name:

Title:

Street:

Affiliation:

City/State/Zip + 4:

Mailing Address:

Phone:

Phone:

Fax:

Fax:

Email:

Email:

Education: Highest Degree:   MD   PhD   MS    MPH    MA    BS    BA   Assoc.  Other:

Year Awarded:              Institution Attended for Degree:

What is your field of microbiology?      Academic     Clinical     Environmental     Industrial     Student 

                                                               (   )              (   )              (   )                 (   )             (   )

Are you a member of ASM?  If yes please include membership #:      (    )Yes    (   ) No

ASM Membership #

Can we use your Email address for communications?   (   ) Yes   (    ) No

Would you be willing to work on a Committee with the ISM?   (    ) Yes   (    ) No

Please make check payable to ISM and return to:

ISM c/o Lynn Schwabe

3349 Maple Leaf Drive

Glenview, IL 60026-1126