Portland Section ACS Affiliate
To become a Portland Local Section American Chemical Society (ACS) Affiliate 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. After you have completed the form and BEFORE you press the BLUE SUBMIT BUTTON at the bottom
** send an email to mgdibblee@icloud.com
** print the form for your record

This ensures that someone knows that you've submitted the form online.

2. Dues are voluntary. If you choose pay dues, there are two options.
** You may print this form and mail a copy of the printed form (which serves as an invoice) with your check for $15
(payable to PORTLAND SECTION ACS) to:
Portland Section American Chemical Society
Attn: Portland Section Affiliate
PO Box 1741
Portland OR 97207-1741
** or you may pay by credit card at a meeting.

3. We do not share email addresses with anyone. To ensure receipt of email notices (from ACS MagnetMail) include "mgdibblee@icloud.com" in your list of email addresses.

4. Please note that this webpage is not monitored. After you've completed an online PORTLAND SECTION Affiliate application please email mgdibblee@icloud.com

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 available at a Section meeting.
______________________________________________________________

I hereby apply for PORTLAND LOCAL SECTION ACS 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
Your answer
PRIMARY ZIPCODE
Your answer
PREFERRED EMAIL ADDRESS
Your answer
PREFERRED PHONE NUMBER
Your answer
EDUCATION & MAJOR
Your answer
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. You also may use a credit card to pay dues at a Section meeting.
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 $____________________

Submit
Never submit passwords through Google Forms.
This content is neither created nor endorsed by Google. Report Abuse - Terms of Service - Additional Terms
Google Forms