| Date | Dr./Mr./Mrs./Miss/Ms. | Name (include middle name) (Please print) |
Title |
| Company | City | State / Zip | Country (if not USA) |
| Phone: Fax: |
Office Office |
Home Home |
| e-mail address | Type of Business | No. of Employees |
| Business Interests (circle all that apply) | |
| Sales Analysis Research Other |
Manufacturing Consulting Inventing |
My local ACS section is
Send your application and check for dues to
Division of Small Chemical Businesses
David Deutsch, Treasurer
138-10 Franklin Ave.Apt. 9L
FLUSHING NY 11355-3309
| Status and Division Dues: 2004 | |
| I am an ACS member Division Member Dues | $15.00 |
| Emeritus Member Dues | $7.50 |
| I am a non-member chemist or a non-chemical professional | $20.00 |
| I am a student | $5.00 |
| Contribution (tax deductible) to Division programs | $ |
Signature
| Participate in a local Subdivision New York, Columbus (circle one) | |
| Advertise in Division publications | Volunteer time and/or services: (circle one) |
| Participate in Division Speakers Bureau | Membership, Program, Finance, Public Relations, Hospitality |
(Please feel free to print this form)
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