APPLICATION FOR SCANZ MEMBERSHIP

SCANZ Treasurer:

Tel: (07) 3365-2132
Fax: (07) 3365-4699
E-mail: b.kobe@uq.edu.au
Postal Address: School of Molecular and Microbial Science, University of Queensland, Cooper Road, Brisbane, Qld, 4072 Australia.

Name:  
(Please print and include formal title e.g. Ms, Mr, Dr, Prof. etc)




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Title             Surname                 First name and initial


Mailing address: (business address preferred)

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E-mail address:

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Membership category:

Regular  ($25)___      Student ($7)___     Corporate ($130)___

• These amounts are reduced to $20, $5 and $100, respectively, if paid by April 1. Membership is on a calendar year basis. Applications received after June 30 will apply for the following year unless otherwise requested.
• Therefore, to join the Society the appropriate fees are $20, $5 or $100, respectively.

Sponsors

Two current members of the Society must sponsor the application. Please write to the Secretary if you do not know any sponsors.

SCANZ Secretary:

Tel: +61 (3) 9905-4606
Fax: +61 (3) 9905-4597
E-mail: Stuart.Batten@monash.edu.au
Postal Address: Monash University, Clayton, VIC 3800, Australia

                          Sponsor 1            Sponsor 2

Name (please print)    ________________     ________________

Signature              ________________     ________________

Student certification

• If requesting student membership, please complete the following and have it certified by a Faculty member of your institution.

The applicant is known to me and is a bone fide student at:

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For the current academic year ______________


Faculty member  __________________    ___________________
                      Name                 Signature

Special interests

• Please indicate your major fields of interest. Students should indicate the degree or diploma sought and the name of their research supervisor if appropriate.

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Payment


I enclose $_________  for membership for the year  ______



Signature__________________________    Date______________