Downloadable Application BIOIRON Membership APPLICATION FOR MEMBERSHIP Application Fee/Annual Dues $80.00 (Regular Membership) | $40.00 (Training Membership) $140.00 (Regular 2-Year Membership) | $60.00 (Training 2-Year Membership) First Name:* Last Name:* Degree(s): Institution: Department: Office Address:* City:* State: Zip / Postal Code:* Country:* Office Telephone:* Office Fax: Home Address:* City:* State: ZIP / Postal Code:* Home Telephone:* E-mail Address:* Gender:* MaleFemale Prefered Mailing Address:* HomeOffice Birthdate: (mm/dd/yyyy)* / / Membership Type:* Regular Membership $80 USD Regular 2-Year Membership(Discounted Rate) $140 USD Regular Members are eligible to vote and may be elected to office in the Society. Training Membership $40 USD Training Membership 2-Year Membership(Discounted Rate) $60 USD Training Members (Student/Resident/Postdoctoral Members) must be in good standing in an academic degree-granting program, post-doctoral fellowship or residency. Evidence for such standing should be provided by endorsement of the applicant’s research advisor or department chair. Training members are eligible to vote but cannot be elected to office. Please email letter of the Department Chair upon completing this application to firstname.lastname@example.org. Payment Section: Payment Information (must be made in U.S. dollars) --Select Card-- Visa MasterCard American Express I have read, understood and agree to the electronic delivery of the data collected and payment amount. SIGNATURE: By selecting “I Agree” I represent and acknowledge that: I have read, understood, and consented to electronic delivery of the data collected and payment entered above. I have granted authorization to in association with WJ Weiser & Associates, Inc. to charge the amount indicated on the credit card provided. I am the authorized user of the credit card listed above and that the associated information entered (account holder name, account number, billing address, etc.) is accurate. I intend the act of selecting “I Agree” to be my legal signature to this agreement. APPLICATION FEE: Enter Security Code: 980963 This is to test whether you are a human visitor and to prevent automated spam submissions.