application for individual membership

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International Association of Geochemistry and Cosmochemistry Application for individual membership TITLE: Dr.[ ] Prof.[ ] Mr.[ ] Mrs.[ ] Ms.[ ] Other(specify) FAMILY NAME: GIVEN NAMES: DEPARTMENT: INSTITUTION: STREET: CITY: STATE: POSTAUZIP CODE: COUNTRY: TYPE OF INSTITUTION: University [ ] University Institute [ ] Government [ ] Private [] Other (specify) [ ] IPOSITION IN INSTITUTION: I PROFESSION Geochemistry [ ] Geology [] Chemistry [ ] Other (specify) [ ] PAYMENT SHOULD ACCOMPANY APPLICATION FORM; CHEQUE/MONEY ORDER PAYABLE TO 'IAGC IN TRUST'. WE DO NOT ACCEPT CREDIT CARD PAYMENTS. IAGC MEMBERSHIP DUES: $10.00US PER YEAR; [] (LIFETIME MEMBERSHIP AVAILABLE AT $150.00US) [] SUBSCRIPTION RATE FOR APPLIED GEOCHEMISTRY $18.00US [] PLEASE FORWARD COMPLETED FORM AND CHEQUE OR MONEY ORDER TO: Dr. Brian Hitchon Secretary, IAGe Alberta Research Council PO Box 8330, Station F Edmonton, Alberta T6H 5X2, Canada

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Page 1: Application for individual membership

International Association of Geochemistry and Cosmochemistry

Application for individual membershipTITLE: Dr.[ ] Prof.[ ] Mr.[ ] Mrs.[ ] Ms.[ ] Other(specify)

FAMILY NAME:

GIVEN NAMES:

DEPARTMENT:

INSTITUTION:

STREET:

CITY:

STATE:

POSTAUZIP CODE:

COUNTRY:

TYPE OF INSTITUTION:University [ ] University Institute [ ] Government [ ] Private []Other (specify) [ ]

IPOSITION IN INSTITUTION:

IPROFESSIONGeochemistry [ ] Geology [] Chemistry [ ] Other (specify) [ ]

PAYMENT SHOULD ACCOMPANY APPLICATION FORM; CHEQUE/MONEY ORDERPAYABLE TO 'IAGC IN TRUST'. WE DO NOT ACCEPT CREDIT CARD PAYMENTS.

IAGC MEMBERSHIP DUES: $10.00US PER YEAR; [](LIFETIME MEMBERSHIP AVAILABLE AT $150.00US) []

SUBSCRIPTION RATE FOR APPLIED GEOCHEMISTRY $18.00US []

PLEASE FORWARD COMPLETED FORM AND CHEQUE OR MONEY ORDER TO:

Dr. Brian HitchonSecretary, IAGeAlberta Research CouncilPO Box 8330, Station FEdmonton, AlbertaT6H 5X2, Canada