STUDENT MEMBERSHIP APPLICATION 555 N. Kensington Ave. | La Grange Park, IL 60526 | T: 800-323-3044 | F: 708-579-8314 | E: [email protected] Apply online at ans.org/join
1. Personal Information ¨ Mr. ¨ Mrs. ¨ Miss ¨ Ms. ¨ Other Birth Date (MO/DAY/YR) / / ¨ Male ¨ Female
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2. Preferences 5. Student Membership Dues ANS memberships are valid for 12 months on an anniversary schedule. Payment must be made Postal mail preference Email preference in full. ¨ Home ¨ Alternate ¨ Home ¨ Alternate DUES AMOUNT ¨ DO NOT include my name in the Membership Directory Student Dues (includes 2 FREE divisions) $ 35 ¨ Referred by ANS Member. Member name or email address optional. Extra Divisions count x $10
Total $ 3. Professional Divisions Choose TWO free technical division memberships. Additional divisions are $10 each. Note: For grad students, Young Members Group (YMG) is an automatic FREE addition to the two 6. Payment divisions. Others may join YMG for $10. YMG may not be substituted for the two divisions included with membership. Pay by check or credit card. Mailing instructions on reverse side.
¨ Accelerator Applications ¨ Nuclear Criticality Safety ¨ American Express ¨ MasterCard ¨ Visa ¨ Diners Club ¨ Discover
¨ Aerospace Nuclear Science & Technology ¨ Nuclear Installations Safety Card # ¨ Decommissioning & Environmental Sciences ¨ Nuclear Nonproliferation Policy
¨ Education, Training & Workforce Develop. ¨ Operations & Power Exp. Date CVV ¨ Fuel Cycle & Waste Management ¨ Radiation Protection & Shielding
¨ Fusion Energy ¨ Reactor Physics Signature ¨ Human Factors, Instrumentation & Controls ¨ Robotics & Remote Systems
¨ Isotopes & Radiation ¨ Thermal Hydraulics
¨ Materials Science & Technology ¨ Young Members Group (YMG) 7. To the Board of Directors I hereby apply for admission to the American Nuclear Society. I certify that the record of my ¨ Mathematics & Computation training and professional experience is correct, and agree that if accepted, I will be governed by 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. 4. Local/Student Section Membership Complimentary membership to an ANS Local Section/ANS Student Section is included with your membership. Please select from the lists on the reverse side and enter your selection here. Signature Date
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Additional Section request 4. Local/Student Sections Enter your selection(s) in section 4. Mailing Instructions Local Sections Student Sections Mail check and invoice American Nuclear Society Carlsbad Air Force Institute of Technology 97781 Eagle Way Central Illinois Brigham Young University Chicago, IL 60678-9770 Chattanooga Chattanooga State Comm. College Chicago City College of New York Express and Overnight ONLY Colorado Clemson University American Nuclear Society Columbia, SC Colorado School of Mines 555 N. Kensington Ave. Connecticut Ecole Polytechnique de Montreal La Grange Park, IL 60526, USA Eastern Carolinas Excelsior College Eastern Washington Florida International University Georgia Georgia Institute of Technology Remit ACH or wire transfers Idaho Idaho State University Account No. 824941 Kansas Iowa State University JP Morgan Chase Bank Long Island Kansas State University 10 S. Dearborn St. Louisiana Kennesaw State University Chicago, IL 60603-2300 Michigan-Ohio King Abdulaziz University Swift Code: CHASUS33 Mississippi Louisiana State University Routing #: 071000013 (ACH) Nevada Massachusetts Inst. of Technology Routing #: 021000021 (wire) New York Metro Missouri Univ. of Science & Tech MUST INCLUDE MEMBER’S LAST NAME Northeastern NY North Carolina State University Northeastern US Ohio State University Fax credit card applications Northern California Oregon State University 708-579-8314 Oak Ridge-Knoxville Pennsylvania State University Piedmont Carolinas Purdue University Pittsburgh Rensselaer Polytechnic Institute San Diego South Carolina State University Savannah River Stevens Institute of Technology Trinity - NM Texas A&M University Virginia Texas A&M-Kingsville Washington DC Three Rivers Community College Wilmington NC U.S. Military Academy Wisconsin U.S. Naval Academy University of California-Berkeley Austria University of California-Irvine France University of Florida India University of Idaho Japan University of Illinois-Urbana-Champaign Latin America University of Maryland Taiwan University of Massachusetts-Lowell United Arab Emirates University of Michigan University of Missouri-Columbia University of Nevada-Las Vegas University of Nevada-Reno University of New Mexico University of Pittsburgh University of Puerto Rico-Mayaguez University of Sharjah University of South Carolina University of Tennessee-Knoxville University of Texas-Arlington University of Texas-Austin University of Texas-Permian Basin University of Utah University of Washington University of Wisconsin-Madison Utah State University Vanderbilt University Virginia Commonwealth University Virginia Polytech Institute and State University
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