International Society for Environmental Epidemiology Membership Application

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First Name

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Last Name                                                                       

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Degree

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Title                                                 Department

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Organization

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Business Address (please note if this is a home address)



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City/Town                                                                   State/Country              Zip code                                

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Office Telephone                                           Fax

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E-Mail



RESEARCH DISCIPLINE - Please indicate up to three areas of research interest:

[  ] Air Quality
[  ] Animal Extrapolation
[  ] Biomarkers
[  ] Cancer Epidemiology
[  ] Cardiovascular Epidemiology
[  ] Environmental Inequity
[  ] Ethics
[  ] Exposure/Dose Assessment
[  ] Hazardous Wastes
[  ] Heavy Metals
[  ] Methodology/Design
[  ] Neurologic Epidemiology
[  ] Noise Research
[  ] Occupation
[  ] Policy & Planning
[  ] Pesticides
[  ] Radiation
[  ] Reproductive Epidemiology
[  ] Respiratory Epidemiology
[  ] Risk Assessment
[  ] Tobacco Smoke
[  ] Statistical Analysis
[  ] Water Quality
[  ] Other(specify)__________________________________

PLACE OF WORK:
[  ] University
[  ] Federal Government
[  ] State/Local Government
[  ] Research Institute
[  ] Industry
[  ] Private Consulting
[  ] Other ____________________________________

Circle the professional organization(s) of which you are now a member:
1. ACE
2. SER
3. IEA
4. APHA
5. ISEA
6. SOEH
7. Other__________________________


Current Membership Fees (check one): (all categories include a one-year print and on-line subscription to Epidemiology)
[  ] Full 1-year Membership (US $220.00) (includes a contribution to developing country memberships)
[  ] Basic 1-year Membership (US $145.00)
[  ] Developing Country 1-year Membership (US $55.00) (Country status based on World Bank macroeconomic indicators)
[  ] Student 1-year Membership (US $55.00) (Please enclose copy of currently dated student ID)

Method of payment: [  ] Check or money order in USD drawn on a U.S. bank
Please make check payable to ISEE.
(Sorry we cannot accept Eurochecks)

[  ] VISA                                                   [  ] MasterCard

[  ] Bank wire transfer. Wire transfer fees from the
originating bank must be paid by the applicant.
Please return this application form under separate cover.___________________________________________________

Expiration date ______/______

Authorizing signature_________________________________



Please mail to: International Society for Environmental Epidemiology
c/o JSI Research and Training Institute
44 Farnsworth Street, Boston, MA 02210-1211 USA
Phone: 617-482-9485 Fax: 617-482-0617

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