American Chemical Society

DIVISION OF PETROLEUM CHEMISTRYINC.

Dr.
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Company Affiliation_____________________________________________________
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I AM APPLYING FOR MEMBERSHIP IN THE PETROLEUM CHEMISTRY DIVISION AS FOLLOWS:

Division Member

Division Affiliate

New

Renewal

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ACS Members or National Affiliates: Please sign the following Statement: I am now a Member or National Affiliate of the American Chemical Society. _____________________________________ (Signature of Applicant)	Applicants for Division Affiliate Status: Please sign here: _____________________________________ (Signature of Applicant)
	Petroleum Chemistry Division Member who stands as Sponsor for the Applicant for Division Affiliate status please sign here: _____________________________________ (Signature of Division Member)

Please make checks payable to Division of Petroleum Chemistry, Inc., ACS, and address your remittance, in U.S. currency, to the Division Treasurer,

Dr. Sarma V. Pisupati Department of Energy and Geo-Environmental Engineering Penn State University 124 Hosler Building University Park PA 16802 Ph: (814) 865-0874 Fax: (814) 865-3248 spisupati@psu.edu

I am interested in serving the Division

Dues in the amount of:	$21 Division Affiliate $18 Member $ 2 Full-Time Student $ 8 Overseas Mailing Fee (outside U.S. and Canada)	American Express	Visa or Mastercard
are Paid by: Cash Check Credit Card		_________________________ (Account Number) Exp. Date_______ Interbank NO _____________

Note:$13 of member dues is allocated to the publishing of the Preprints