Docstoc

WACBE nembership form - 國立成功大學國際會議暨專案用伺服器

Document Sample
WACBE nembership form - 國立成功大學國際會議暨專案用伺服器 Powered By Docstoc
					                                              MEMBERSHIP FORM
Please Select                                                 Membership Category

  Apply for Membership [   ]     Renew Membership [     ]        [ ] Life Member          USD 500 per life
                                                                 [ ] Regular Member       USD 50 per year

First (Given) Name:                                              [ ] Student Member       USD 10 per year

Last (Family) Name:                                           Select payment years
                                                                 2007 [ ]   2008 [    ]   2009 [   ]   2010 [   ]
Name in Chinese
                                                                 2011 [ ]   2012 [    ]   2013 [   ]   2014 [   ]
Affiliation:                                                     2015 [ ]   2016 [   ]    2017 [   ]   2017 [   ]

Position                                                         To certify your student status, please provide the name
                                                                 and signature of your supervisor.
Interest in BME
                                                                 Supervisor Name

                                                                 Supervisor Signature



                                                              Payment by Check or Bank Draft
Postal Address
                                                                   Amount to be charged
Department of Physics and Astronomy
                                                                   Check/Draft Number
University of North Carolina at Chapel Hill
                                                              Payment by Credit Card
Chapel Hill, NC 27599
                                                                   Amount to be charged
Email: jpl@physics.unc.edu
                                                                   Type of Credit Card
Phone: 919-962-3012                                                         [ ] Discover
                                                                            [ ] Master Card
Fax: 919-962-0480                                                           [ ] Visa
                                                                            [ ] American Express

                                                                   Name on the Card
Reference
For membership application, please name one current
WACBE member who could serve as a reference for your               Card Number
application.
                                                                   Expiration Date
   Reference Name Prof. Xiaoping Hu
                                                                   Authorization
   Reference Signature                                             Signature



    Please return the form to: Zong-Ming Li (c/o Diann DeCenzo), WACBE Secretary, 405 Center for Bioengineering, 300
     Technology Drive, Pittsburgh, PA 15219. Phone: +1 412 648 2000, Fax: +1 412 648 2001, Email: info@wacbe.org

				
DOCUMENT INFO