MICR MEMBERSHIP APPLICATION

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					                           MICR MEMBERSHIP APPLICATION
Only complete this form for Minorities in Cancer Research (MICR) membership if you are an existing AACR member. If
you are not yet an AACR member and want to join both AACR and MICR, you can download the official AACR
Membership Application from the AACR website at www.aacr.org and check the box for MICR membership on the form.

                                                                               AACR Member #:________________

CONTACT INFORMATION (please print)

Name: ______________________________ ____________________________________          ________________
        (Last)                              (First)                                   (M.I.)
Present Position:_____________________________________ Department:_________________________________

Institutional Affiliation:______________________________________________________________________________

Institutional Address:_______________________________________________________________________________

City:______________________ State/Province:________________________ Country:_________________________

Zip/Postal Code:__________________         Telephone:________________________ Fax:_________________________

Email Address:_____________________________ URL/Website Address:___________________________________

□ Please check here, if the address above is different and should replace your address in our membership database.


 AACR MEMBER TYPE (please indicate)                        DEMOGRAPHICAL INFORMATION (Information concerning
                                                           gender and ethnic background is solicited to enable the Association to
                                                           ensure that its programs are appropriately serving all members of the
                                                           cancer research community.)

□ Active         □ Affiliate        □ Associate           Race/Ethnicity: (please check only one)
□ Emeritus       □ Honorary         □ Student             □ African American/Black □ Alaskan Native    □ Asian
                                                          □ Caucasian               □ Hispanic □ Native Pacific Islander
                                                          □ Native American         □ Other

                                                          Gender:            □ Male                         □ Female
STATEMENT (please indicate)
Why are you interested in joining Minorities in Cancer Research?_______________________________________________

___________________________________________________________________________________________________

___________________________________________________________________________________________________

Applicant Signature:_______________________________                                  Date:_____________________________

Please send application or direct inquiries to:
MINORITIES IN CANCER RESEARCH
American Association for Cancer Research
615 Chestnut Street, 17th Floor
Philadelphia, PA 19106-4404
Telephone: 215-440-9300 ● Fax: 215-440-9412
E-mail: micr@aacr.org ● Website: www.aacr.org

     WORKING TO PREVENT & CURE CANCER WHILE MEETING THE PROFESSIONAL NEEDS & ADVANCING THE CAREERS OF MINORITY SCIENTISTS.