CIC Membership Application Form

CIC (CSC, CSChE, CSCT) New Membership Application Form 2006

The Chemical Institute of Canada
Canadian Society for Chemistry
Canadian Society for Chemical Engineering
Canadian Society for Chemical Technology

(GST #108076431)

NOTE:
Membership applications will not be processed until payment has been received.
Applications take approximately two weeks to be processed. Membership numbers will not be assigned until processing has been completed.

If you are making a payment by credit card:
1) complete the on-line membership application
2) Click on "credit card payment by fax" at the bottom of this page
3) print and complete the form and fax it to 1- 613-232-5862

or mail your cheque or money order to CIC, 130 Slater Street, Suite 550, Ottawa, ON K1P 6E2.

2006 Membership fee $148.40 including GST
($159.60 including HST for residents of NB, NS and NL).

2006 Postdoc $74.20 including GST
($79.80 including HST for residents of NB, NS and NL).
Valid for up to three years from year of graduation.

2006 First Year after Graduation $74.20 including GST
($79.80 including HST for residents of NB, NS and NL).

2006 Graduate Students $43.99 including GST
($47.31 including HST for residents of NB, NS and NL).

2006 Undergraduate Students $26.50 including GST
($28.50 including HST for residents of NB, NS and NL).

Please identify and describe yourself (* indicates a required field):

PERSONAL INFORMATION

*	Prefix:	Dr. Mr. Mrs. Ms.

*	Last Name:

*	Given Name(s):

*	Home Address:

*	Home Telephone:	( )

*	E-mail Address:	Type “not yet" if you still have no e-mail address.

*	Date of Birth:	D / M / Y (ex: 18 / 04 / 1950)

*	EDUCATION: (Curriculum Vitae (resume) must be submitted if you are an applicant educated outside of Canada) [Institution; Dates From/To; Course; Diploma/Degrees]

EMPLOYER INFORMATION

*	Name of Employer:	(or type "none")

	Address of Employer:

	Telephone:	( ) [Extension: ]

	Fax:	( ) [Extension: ]

	E-mail Address:

	Product and/or function of employer:

*	EMPLOYMENT (Applicants from outside of Canada must submit Curriculum Vitae (resume).) [Employer; Position; Date From/To]

*	Area of Expertise:

	Other Professional or Scientific Affiliations:

MEMBERSHIP INFORMATION

DIVISION CHOICE:

Please choose your FREE
primary Division choice:

(Check others below as
secondary Division -
$5.30 each)

PRIM		SEC
	Analytical
	Biological / Medicinal
	Biotechnology
	Catalysis
	Chemical Education
	Economics and Business Management
	Environment
	Inorganic
	Materials
	Macromolecular Science and Engineering
	Organic
	Physical and Theoretical
	Process Safety Management
	Rubber
	Surface Science
	Systems and Control

Declaration: By submitting this form, I hereby certify that the foregoing statements are correct and are made as a condition of admission to membership. If accepted, I agree to be governed by the Charter, By-laws and regulations of the said Societies as they now or may hereafter become, and I undertake to promote the objects and interests of the Societies and The Institute. If I wish to withdraw membership I shall advise the Secretary in writing and, after payment of any dues that may at that time be owed by me.

Sponsor Verification:
Please supply information on a sponsor (a person in a position of responsibility, e.g. employer, supervisor, professor and, preferably, a member of the CIC).

*	Name:

*	Address:

*	Telephone:	() [Extension: ]

*	E-mail Address:

I hereby certify that, to the best of my knowledge, the statements made by the applicant for membership in The Chemical Institute of Canada are correct.

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Click here for credit card payment by fax.