MEPCIS Revised 12-27-09

Mid-Eastern Pennsylvania Clinical Instrumentation Society

2010 MEMBERSHIP APPLICATION

Date ____________ Membership year 2010 New or Renewal (please circle)

Contact Name/Person ____________________________________________________________________

Institution/Company _____________________________________________________________________

Address _______________________________________________________________________________

City, State & Zip ________________________________________________________________________

Phone _________________ Fax _________________ Email _____________________________________

Type of Membership New Member Fee Discount Renewal Fee

(Check one) and Renewal after March 30^th before March 30^th

^{_____ Group $ 67 $ 62}

^{_____ Full $ 23 $ 20}

^{_____ Student $ 9 $ 7}

Membership is calendar based (Jan 1 – Dec 31)

Make checks payable to: MEPCIS

Please print out and send completed application and check to:

Seth Lawall

1746 Michael Drive

Whitehall, Pa 18052

Additional Members Names:

^{______________________________ _____________________________ _____________________________}

^{______________________________ _____________________________ _____________________________}

^{______________________________ _____________________________ _____________________________}

^{______________________________ _____________________________ _____________________________}

MEPCIS bylaws limit corporate/commercial groups to two voting members, please list below

^{1. _____________________________________ 2. _____________________________________}

Keep up to date and visit the MEPCIS web page at: www.mepcis.com