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( ) New Membership
$30 -
2 years
( ) Renewal
$30 –
2 years
( ) Student $30 – 2 years |
( ) Emeritus Member
( ) Apply for Emeritus
status
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Dr./Mr./Ms./Mrs.:
Name:
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Title:
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Street:
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Affiliation:
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City/State/Zip + 4:
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Mailing Address:
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Phone:
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Phone:
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Fax:
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Fax:
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Email:
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Email:
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Education: Highest Degree:
MD
PhD MS MPH
MA
BS BA Assoc. Other:
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Year
Awarded:
Institution Attended for Degree:
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What is your field of
microbiology?
Academic Clinical
Environmental
Industrial Student
(
)
(
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(
)
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( )
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Are you a member of ASM? If yes
please include
membership #: (
)Yes
( ) No
ASM Membership #
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Can we use your Email address for
communications?
( ) Yes ( ) No
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Would you be willing to work on a
Committee with
the ISM? ( ) Yes
(
) No
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Please
make check payable to ISM and return to:
ISM c/o Lynn Schwabe
3349 Maple Leaf Drive
Glenview, IL 60026-1126
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