Apply online at MEMBERSHIP APPLICATION ans.org/join 555 N. Kensington Ave. | La Grange Park, IL 60526 | T: 800-323-3044 | F: 708-579-8314 | E: [email protected]

1. Personal Information ¨ Dr. ¨ Mr. ¨ Mrs. ¨ Miss ¨ Ms. ¨ Prof. ¨ Other Birth Date (MO/DAY/YR) / / ¨ Male ¨ Female

Name First M. I. Last

Street City

State/Province ZIP Country

Phone Cell

Email

Employer Title

Street City

State/Province ZIP Country

Phone Email Education Grad Date (MO/YR) optional College/University / Major Degree

2. Preferences 6. Voluntary Contributions Become an ANS Champion and support the Society’s annual fund. Please select donation level Postal mail preference Email preference and add to the payment section below. Contributions are tax deductable as allowed by law. ¨ Home ¨ Business ¨ Home ¨ Business ¨ Legacy $1,000 ¨ Patron $500 ¨ Benefactor $250 ¨ Advocate $100 ¨ Supporter $50 ¨ DO NOT include my name in the Membership Directory

¨ I am a licensed Professional Engineer (P.E.) ¨ Referred by ANS Member. 7. Membership Dues Member name or email address optional. ANS memberships are valid for 12 months on an anniversary schedule. Payment must be made in full. Contact the ANS Membership Department to learn about Lifetime Member rates. DUES AMOUNT 3. Work Established Member – age 36 & over $ 175 Enter corresponding codes from reverse side that best match your position, job function, and industry. Young Member – age 35 & younger or graduated 2016 or later $ 130 Position Job function Industry Extra Divisions $10 each (2 included free)

Voluntary Contributions from section 6

4. Professional Divisions Total $ Choose TWO free technical division memberships. Additional divisions are $10 each. Note: Professionals under 36 are automatically included in the Young Members Group in addition to Outside the U.S., Mexico and Canada, dues include Nuclear News online only. Note: ANS dues the two free divisions. Others may join YMG for $10. YMG may not be substituted for the two divisions are tax deductible as allowed by law. Consult your tax advisor. Membership dues subscription included with membership. allocations: Nuclear News - 49%. ¨ Accelerator Applications ¨ Nuclear Criticality Safety ¨ Aerospace Nuclear Science & Technology ¨ Nuclear Installations Safety 8. Payment ¨ Decommissioning & Environmental Sciences ¨ Nuclear Nonproliferation Policy Pay by check or credit card. Mailing instructions on reverse side. ¨ Education, Training & Workforce Develop. ¨ Operations & Power ¨ American Express ¨ MasterCard ¨ Visa ¨ Diners Club ¨ Discover ¨ Fuel Cycle & Waste Management ¨ Radiation Protection & Shielding

¨ Fusion Energy ¨ Reactor Physics Card #

¨ Human Factors, Instrumentation & Controls ¨ Robotics & Remote Systems Exp. Date CVV ¨ Isotopes & Radiation ¨ Thermal Hydraulics

¨ Materials Science & Technology ¨ Young Members Group (YMG) Signature ¨ Mathematics & Computation

5. Local/Student Section Membership 9. To the Board of Directors I hereby apply for admission to the American Nuclear Society. I certify that the record of my Complimentary membership to an ANS Local Section/ANS Student Section is included with your training and professional experience is correct, and agree that if accepted, I will be governed by membership. Please select from the lists on the reverse side and enter your selection here. the Society’s Code of Ethics (ans.org/coe), Bylaws, and Rules (ans.org/br), and will adhere to the Respectful Behavior Policy (ans.org/rbp) as long as I remain a member. Primary Section

Additional Section request Signature Date 3. Work Enter corresponding code for your position, job function, and industry in section 3. Mailing Instructions Position (code) Job Function (code) Industry (code) Mail check and invoice Not Employed (NE) Engineer Not Employed (NE) American Nuclear Society 97781 Eagle Way Retired/Emeritus (RE) Nuclear Engineer (NE) Retired (RT) Chicago, IL 60678-9770 President (PR) Electrical Engineer (EE) Active Military (AM) Vice President (VP) Mechanical Engineer (ME) Construction Company (CN) Express and Overnight ONLY Chief Nuclear Officer (CN) Chemical Engineer (CE) Consulting Company (CT) American Nuclear Society Chief Operating Officer (CO) Other Engineer (OE) Educational Institution (EI) 555 N. Kensington Ave. La Grange Park, IL 60526, USA Chief Financial Officer (CF) Engineering Firm (EF) Specialist Director/Department Head (DR) Government Agency (GA) Health Physicist (HP) Owner (OW) Manufacturer (MF) Remit ACH or wire transfers Chemist (CH) Account No. 824941 Manager (MG) Medical Institution (MI) Technician (TC) JP Morgan Chase Bank Supervisor (SP) National Lab (NL) Scientist (SC) 10 S. Dearborn St. Analyst (AN) Private Research/Test Lab (PR) Chicago, IL 60603-2300 Chief/Senior Engineer (CS) Operations Service Company (SV) Swift Code: CHASUS33 Engineer (EN) Reactor Operator (RO) Student (ST) Routing #: 071000013 (ACH) Routing #: 021000021 (wire) Consultant (CT) Plant Operations (PO) Supplier (SU) MUST INCLUDE MEMBER’S LAST NAME Project Manager (PM) Utility (UT) All Other Professor (PR) Other (OT) Educator (ED) Fax credit card applications Adjunct/Assistant Professor (AP) 708-579-8314 Student (ST) Instructor (IN) Sales/Marketing/PR (SA) Research Assistant (RA) General/Corporate Mgmt (MG) Student (ST) Manufacturing (MF) Military Officer (MO) Other (OT) Other (OT)

5. Local/Student Sections Enter your selection(s) in section 5.

Local Sections San Diego Excelsior College University of Carlsbad Savannah River Florida International University University of Central Trinity - NM Institute of Technology University of Illinois-Urbana-Champaign Chattanooga University of Chicago Washington DC State University University of -Lowell Wilmington NC State University University of Columbia, SC Kennesaw State University University of -Columbia King Abdulaziz University University of -Las Vegas Eastern Carolinas Austria State University University of Nevada-Reno Eastern Washington France Massachusetts Inst. of Technology University of Georgia India Missouri Univ. of Science & Tech Idaho Japan State University University of -Mayaguez Kansas Latin America State University University of Sharjah Long Island Taiwan State University University of Louisiana State University University of -Knoxville Michigan-Ohio University of -Arlington Mississippi Rensselaer Polytechnic Institute University of Texas-Austin Nevada Student Sections South Carolina State University University of Texas-Permian Basin Stevens Institute of Technology University of Metro Air Force Institute of Technology Texas A&M University University of Washington Northeastern NY Texas A&M-Kingsville University of Wisconsin-Madison Northeastern US Chattanooga State Comm. College Three Rivers Community College Northern City College of New York U.S. Military Academy Oak Ridge-Knoxville Clemson University U.S. Naval Academy Virginia Commonwealth University Piedmont Carolinas University of California-Berkeley Virginia Polytech Institute and Pittsburgh Ecole Polytechnique de Montreal University of California-Irvine State University

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