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Membership Form
Please
send to: Dr. Charles E. Ribak Secretary/Treasurer of Cajal Club Department of Anatomy
& Neurobiology University of California at Irvine School of Medicine
Irvine, CA 92697-1275 USA
Please complete and return with your Membership Fee.
NAME
ADDRESS
CITY/STATE/ZIP
EMAIL
FAX
MEMBERS RESIDING OUTSIDE USA SHOULD MAKE PAYMENT IN
US DOLLARS ONLY. We cannot accept credit card payments.
MEMBERSHIP FEE (Please check one or more)
___ Active Member ..............$50.00
___ Student/Postdoc Member ....$10.00
___ Retired Member
.............$0
Please make checks payable to: CAJAL CLUB
Please
use Pay Pal if it is more convenient. The paypal button can be found below the form:
ANNUAL DUES FOR 2011-2012
Please complete and return with 2011-2012 Cajal Club annual membership
dues.
NAME
ADDRESS
CITY/STATE/ZIP
EMAIL
FAX
MEMBERS RESIDING OUTSIDE USA SHOULD MAKE PAYMENT IN U.S. DOLLARS DRAWN ON A U.S. BANK. We cannot accept credit
cards for Cajal Club dues payments
MEMBERSHIP DUES (PLEASE CHECK ONE)
___ Active Member ………………………….$50.00
___ Student/Postdoc Member…………….$10.00
___ Retired Member……………………..…$0
TAX EXEMPT DONATIONS
___ Donations for support of student activities (i.e., travel grants,
poster prizes, etc.) Please indicate whether you want a pin (they are in limited supply).
Please make
checks payable to: Cajal Club
Please return completed form with your check to:
Charles E. Ribak, Ph.D. Cajal Club, Office of the Secretary/Treasurer Department of Anatomy & Neurobiology University of California
at Irvine Irvine, CA 92697-1275
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Click here to pay for a full active membership |
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Click here for a student membership |
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