THE CHEMISTS' CLUB MEMBERSHIP APPLICATION Please complete this form and mail to: The Chemists' Club Attn: Membership Director 3 West 51st Street New York, NY 10019 Name of Applicant   Title   Company Name   Company Address   Business Phone   Fax   Email Address   Residence Address   Residence Phone   Fax   Send all Club Correspondence to:   _____ Home    _____Business Would you like your information to be included in our membership directory? __ Yes   __No If yes, would you prefer your home or business address be used?  __ Home   __ Business Academic Degree   Granted By   Year   Credit Card No.   Expiration:   I am Applying for: Annual Dues   _____ Regular Membership * $400.00 _____ Corporate Membership (includes 4 people from one institution) $1200.00     Signature ______________________________   Date: _____________ * reduced rates available for junior/academic members upon request