Membership

AMERICAN CYTOGENETICS CONFERENCE

Membership Form

(please only complete the membership form if you are not registering for the meeting – meeting registration form will be sufficient for membership form if you are registering)

A.  Member Information:

Name: _____________________________________________________                                                                                                         

             First                            Middle                           Last

Address: _________________________________________________

                        Institution    

               _________________________________________________

                        Street Address

City:       _________________________________________________

State/Country:  _____________________________ Zip/Postal Code: ______________

E-mail: ___________________________________  Phone:  _(_____)________________

B. Membership Dues

____Full Membership (2012/2013)                              $100.00/2 years

____Trainee Membership (2012/2013)                      $  40.00/2 years

            (must be accompanied by a letter of training status from mentor)

C. Method of Payment

____Check payable to the American Cytogenetics Conference (please send to address shown below)

____Credit Card

            Credit Card Type:____Visa     ____ Mastercard         

            Credit Card Number: ______________________________________________________              

            Credit Card Expiration Date: ________________________________________________

            Cardholder’s Name(exactly as it appears on card): _______________________________

            Billing Address:­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­__________________________________________________________

Please make checks payable to: American Cytogenetics Conference and mail to the following address: