Please Send Your Dues To: Please E Mail This Form to Bob Kohmescher at Or Send to the WS P.O

Registration Form Please send your dues to: Please e‐mail this form to Bob Kohmescher at [email protected] or send to the WS P.O. The Watsonian Society Box. If you encounter any problems completing this form, please contact P.O. Box 49372 Atlanta, GA 30329 Bob by e‐mail or by phone – 770-722-2192

Membership Type

Active or Retired Member $15 (1 Year) or $40 (3 Years) plus (if applicable) $10 (Initiation fee) or $5 (Lapsed reinstatement)

Associate (non-voting) member $10 (1 Year) or $25 (3 Years) plus (if applicable) $5 Initiation/lapsed reinstatement

Lifetime $225 Option A ( 52-59 years old) or $150 Option B (60-69 years old) or $75 Option C (70+ years old)

Total Amount: $______.00 Are you updating current membership information? Yes No Are you applying as a new member? Yes No Are you applying as an associate member? (see webpage) Yes No Are you now or have you ever been a public health advisor at CDC/ATSDR? Yes No Are you retired? Yes No

Name First name Home e‐mail

First name AKA Home phone (preferred nickname) Middle initial Work address 1 Last Name Work address 2 Last Name AKA (maiden Work – City name) Suffix (Jr, III, etc) Work – State Home address 1 Work – Zip Home address 2 Work – e‐mail City Work –phone State Zip

Please indicate if you are interested in volunteering by placing an X in the right column Volunteering I’m interested in serving as a mentor (you must be GS‐12 or above) Yes No I’m interested in working on a committee? Yes No

Miscellaneous Information Year of birth If you are still working, please , please answer the following questions: Current assignment (Center/Division) Location (e.g., Atlanta, Chicago, Abidjan)