Portland Section ACS Affiliate Membership
To become a Portland Local Section American Chemical Society (ACS) Affiliate Member complete the form below.
A Portland Local Section ACS Affiliate:
Is welcome at all Portland Section meetings, activities and events
Receives all Section notices
May pay voluntary dues of $15
May neither vote for nor hold an elective position
May participate in committees

Instructions:
1. Complete the FORM below.
2. Dues are voluntary. If you pay voluntary dues, PRINT the form and mail it with your check for $15 (payable to Portland Section ACS) to:
Portland Section American Chemical Society
Attn: Bernard Carlsen/Martha Dibblee
PO Box 1741
Portland OR 97207-1741
3. Don't forget to click the BLUE Submit button whether or not you print the form to use as in invoice for payment.
4. We do not share email addresses with anyone. To ensure receipt of email notices include "mgdibblee@icloud.com" in your list of email addresses.

Membership cards are available for those who want them. Please email mgdibblee@icloud.com if you want a membership card. Your membership card will be mailed to the address provided below.
______________________________________________________________

I hereby apply for Local Section Affiliate Membership:

FIRST NAME
Your answer
LAST NAME
Your answer
PRIMARY COMPANY NAME
Your answer
PRIMARY DEP'T NAME & MAIL STOP
Your answer
PRIMARY MAILING ADDRESS
Your answer
PRIMARY CITY
Your answer
PRIMARY STATE
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PRIMARY ZIPCODE
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PREFERRED EMAIL ADDRESS
Your answer
PREFERRED PHONE NUMBER
Your answer
EDUCATION & MAJOR
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FOR TEACHERS: GRADE LEVEL
VOLUNTARY DUES
If you submit a check to the Section, keep a copy of this form (printed) as your record of payment.
AMOUNT ENCLOSED
Print and enclose a copy of this form if you submit voluntary dues payment.
Your answer
CHECK NUMBER
Print this form form for your records.
Your answer
If you choose to pay $15 dues, this form is your Invoice. PRINT this form before clicking the submit button
PORTLAND SECTION USE ONLY

Received by ______________________________________________

Date____________________ Amount $____________________

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