New Member Registration

  
 
DATE:
 

NAME:    TITLE:

 

COMPANY NAME (INCLUDE DEPT.): 

 

INDUSTRY-CHEMICAL:   OTHER:

 

BUSINESS ADDRESS:    ZIP:

 

HOME ADDRESS:     ZIP: 

 

HOME PHONE:                           BUSINESS PHONE:

 
FAX NO: E-MAIL ADDRESS:  

WIFE(HUSBAND) NAME/NICKNAME: 

 

IF APPLICABLE, NAME OF COUNTRY CLUB MEMBERSHIP:   

 

SEND CORRESPONDENCE TO (CHECK ONE):           HOME:                      OFFICE:

 

SPONSERED BY: (CHEMICAL CLUB MEMBER'S NAME)

 

HIS/HER SIGNATURE:____________________________________________________

  

YOUR SIGNATURE: _____________________________________________________

  

Applicant's Note:

This form, completely filled out, should be mailed to:

Please send dues of $110.00 along with application.

Make Check payable to Chem Club of Philadelphia.

Bert Dahlstrom
340 Myrtle Avenue
Woodbury, New Jersey 08096

Phone 856-853-7452
Fax 856-853-0925

email address: bert822@verizon.net

Failure to follow above procedure will result in non-admission

Would you be interested in serving on one of our operating committees?

Scholarship                  Winter Meetings                      Golf

                                                                        

Membership Committee Use Only

Date approved:                        

Classification: (check one)

            Regular:                      

            Allied:                          

Signature of Chairman: