THE CHEMISTS' CLUB MEMBERSHIP APPLICATION Please complete this form and mail to: The Chemists' Club Attn: Membership Director 40 West 45th Street New York, NY 10036
	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 _____ Junior Membership (under 35 years of age) $200.00 _____ Retired $200.00 _____ Academic Membership (must be enrolled in an accredited academic institution) $200.00 _____ Corporate Membership (includes 10 people from one institution) $1200.00     Signature ______________________________   Date: _____________